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SAN JC 7UIN COUNTY PUBLIC HEALTH RVICES <br /> "rNVIRONMENTAL HEALTH DIVISION <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 Cl CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#CVC o cl ?1"1 0 a'O I PROJECT CONTACT PHONE# 5�e3-4pfr,� <br /> FACILITY NAME YUCK( PHONE# <br /> ADDRESS <br /> CROSS STREET Q G <br /> OWNER OPERATOR PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAMEPHONE# <br /> CONTRACTOR ADDRESS L'�.fl 111 CA LIC# q I CLASS,/a4l LA <br /> INSURER WORKER COMP# U) 01I9060 <br /> FIRE DISTRICT c PERMIT# <br /> LABORATORY NAME S COUNTY PHONE# <br /> SAMPLING FIRM cJ PHONE k - <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT 8 PAST) DATE INSTALLED <br /> 39- - j bD I <br /> 39- aCg, .600 61I <br /> 39- <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 AGENTS 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 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 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br /> APPLICANTS SIGNATURE - T I{ y--�+'"(v TITLE DATE <br /> Cl APPROVED APPROVED WITH CONDITION(S) Cl DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE 144-Y-- q <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE VUBM41TTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> � <br /> CONDITIONS: <br /> "s <br /> i <br /> EH 23 046(REVISED 10/19198) Page 3 <br />