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N JOAQUIN COUNTY PUBLIC HEA' `H SERVICES <br /> ENVIRONMENTAL HEALTH Dl,AION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FON PFRMANENT/TEMPORARY CLOSURE(IR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(N)EXPIRES 90 DAYS FROM THE APPROVAL DATE DO NOT WRIT[ IN ANY SHADED AREAS INDICATE PERMIT TYPE; <br /> J� REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# 3 PROJECT CONTACTXW" PHONE# <br /> FACILITY NAME /W /,) PHONE# <br /> ADDRESS C� <br /> CROSS STREET <br /> OWNEROPERATOR PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME eM <br /> CONTRACTOR ADDRESS CALIC#INSURER r [� •� WORKER COMP# Z <br /> FIRE DISTRICT c�, PERMIT# <br /> LABORATORYNAME cJ< COUNTY aM.. .• <br /> q SAMPLING FIRM PHONE # <br /> j TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTSPRESENT 8 PAST DATE INSTALLED <br /> { <br /> 39- 0 3 1 o I <br /> i 39- 0 2 U B SO/:wlG <br /> 3 - td o/; <br /> 39- <br /> 39- <br /> i <br /> I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 7 <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 BECCMr-SUBJECT TO WORKER'S COMPENSATI N LAWS OF CALIFORNIA.• CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT TH ERFO CE OF TH- ORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAW OF LIFORN .' <br /> � J� G <br /> APPLICANT'S SIGNATQRE •? TITL //I.y/.L DATE <br /> ❑ APPROVEDAPPROVED WITH CONDITIONS) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME (-,L.(0I �()j Ate. IfeDATE_ <br /> u <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EMD FOR APPROVAL PRIOR TO COMMENCI G WORK. <br /> CONDITIONS: <br /> c,.-5 JA- A,;+ tW <br /> O A ©-L f�, <br /> a i 8 <br /> .5(n_V�SEO GB/13n'ei Fage 3 <br /> ••i inA <br />