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�. SAJOAQUIN COUNTY PUBLIC HEALT'- SERVICES <br /> ' 1 ENVIRONMENTAL HEALTH DIWb N <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# .3 PROJECT CONTACT PHONE# <br /> ZT <br /> FACILITY NAME PHONE# <br /> ADDRESS Cl <br /> CROSS STREET <br /> OWNEROPERATOR PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME PHONE# <br /> CONTRACTOR ADDRESS CA LIC# CLASS <br /> INSURER C [{ A WORKER COMP# <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME COUNTY <br /> .� SAMPLING FIRM PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS IFRESENT 8 PAST DATE INSTALLED <br /> 39- 0 Z33 l o l Rsn <br /> 39- <br /> 39- 14,454P14-ye- <br /> 39_ <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 /> j REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 7 <br /> 17 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 CON% ATI 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 L,A, OFC IFORN ' <br /> APPLICANTSSIGNAT6RE TITI-5, DATE • V <br /> Al <br /> ❑ APPROVED FVAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW ANO/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME .�� � /L A DATE. q <br /> (bg/Io <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> ores Q r A.:4r "oulpp-A rPu," <br /> �)�2id�-� of -4� cV rol�o.fa Nt.�le( ral Li rloc a vl.« }y <br /> a.lrcIA& C <br /> EH<0 046(REVISED 08/13/99) Page 3 <br /> J <br /> Oro f <br />