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SAN JOAQU-in COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> HIS PERMIT FOR PERMANENTI7EMPORARY CLOSURE ORABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> TORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY DIIADEO ARCAS. INDICATE PERMIT TYPE: <br /> i <br /> 1 REMOVAL ❑ TEMPORARY CLOSURE d CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA 317E YPR CONTACT IPHONE# <br /> FACILITY NAME I PHONE# <br /> ADDRESS I 79N 952-Io <br /> CROSS STREET <br /> OWNER OPERATOR IPHONsp <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME UfZ-2;0 "Cfll4f4V4Ij4fi I PHONEIIItS343 <br /> CONTRACTOR ADDRESSI !I/L CA LIC O 1 CLASS Z <br /> INSURER AF e- awNVItbjlWORKER COMP# <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAMEi;=, AWlVjj4& COUNTY PHONE rt 56 0tT�IDO <br /> AMP M S <br /> I'MUNI: # 10 41-703 <br /> TANK INFORMATION <br /> TANKID# TANK SIZE TANK C NTENTS PRESENT& PAS DATEINSTALLED <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT <br /> 9-39- <br /> 39- <br /> 39•39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL INORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCEe,STA-M MWe,FEDERAL LAWS,AND RVLZe ANO <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, OWNER OR UCENSED AGENTS SIGNATURE CERTIF198 THE FOLLOWNO: 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT is IssueO•I SHALL 4'MPLOY PRRSONs SUG.,rCT TO <br /> WORKERS COMPENSATION LAWS OF CALIFORNIA' <br /> APPLICANTS SIGNATURE_ I �-- - ,TITLE ary_094141L DAT I OD , <br /> ❑ APPROVED 0 APPROVED WITH CONDITION($) O DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATION$FROM THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCINO WORK. <br /> CONDITIONS: <br /> :H 23 018(REVISED 08/13189) Pepe 3 <br /> -i.l <br /> 60GSL I-I7Z-0656W,laeul6U3es1n INV 9V LODZ '80JsQweaN 'ArPlid <br />