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SAN . \QUIN COUNTY PUBLIC HEALTI 'ERVICES `ENVIRONMENTAL HEALTH DIVIMN APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: REMOVAL OF PROPOM ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE \IAPOL 01PiM& OML-1 -Tt4g P)C( tinl6r iANKS Aft TO RtMR16J " • . • CONTRACTOR •' • 39- 15 000 I 19L915 39- 1 00 CiNaZ SJDM U L 1 mal CONDITIONS: 39- 39- 48.6 39 - /#eu TANK INFORMATION CONTRACTOR •' • 39- 15 000 I 19L915 39- 1 00 CiNaZ SJDM U L 1 39- CONDITIONS: 39- 39- 48.6 39 - r"IL M...i, ` bC. w:+ - YC - Z- ,-Lzl /#eu TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- 15 000 I 19L915 39- 1 00 CiNaZ SJDM U L 1 39- CONDITIONS: 39- 39- " ✓ 39 - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING 'I 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 TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' APPLICANT'S SIGNATURE TITLE `a.- a T %I'l w 1 DATE 6 / ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAMEO/.J/% Y / 'k� DATE L - `. ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: " ✓ r"IL M...i, ` bC. w:+ - YC - Z- ,-Lzl EH 23 046 (REVISED 08/13/99) Page 3