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SAN •" AQUIN COUNTY PUBLIC HEALTI" SERVICES <br /> �rENVIRONMENTAL HEALTH DIVY...ON <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 /> Cl REMOVAL TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#CfV_5556_A2_j4V I PROJECT CONTACT / PHONE# to <br /> FACILITY NAME PHONE# <br /> ADDRESS 4AA)S 57_*7OU <br /> CROSS STREET <br /> OWNER OPERATOR { PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME / I PHONE# SbSTr <br /> CONTRACTOR ADDRESS SrI CA LIC# 7L I CLASS fWZ <br /> INSURER cl clWA IWORKERCOMP# <br /> FIRE DISTRICT I PERMIT# <br /> LABORATORY NAME \�(�, COUNTY IPHONE# ,9600 <br /> SAMPLING FIRM I PHONE # (o, <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- 3 B7 <br /> 39 QZ 12K <br /> 39 /i <br /> 39- <br /> 39- <br /> 39- <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. '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 COMPE SATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING- 'I CERTIFY THAT IN TH ORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATIALAW§,C ORNIA.' <br /> APPLICANT'S SIGNATU TIT Y DATE_ <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> //�� (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) ��/ <br /> PLAN REVIEWER'S NAMED� DAT;,; LTJ r <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EH FOR APPROVAL PRIOR TO COM MENCINNGG WORK. <br /> CO DI NS: <br /> i <br /> EH 23 046(R ED 08/13/99) Page 3 <br />