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SAN Jo,�UIN COUNTY PUBLIC HEALTHs,,,tRVICES ENVIRONMENTAL HEALTH DIVISION 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: RU REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE 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.' jjjjjj DATE�U APPLICANT'S SIGNATURE �(M'1 � TITLE ��T��T��,, F[PLAN PROVED APPROVED WITH CONDITION(S) ❑DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) .�jJ�� ` tt -' DATE C/ / - IEWER'S NAME 1 M�^DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. r1 CONDITIONS: '� i- � s EH 23 046 (REVISED Uan Slav) FACILITY INFORMATION EPA SITE # Cf�C S FACILITY NAME PROJECT CONTACT PtCk H AM I L fD fj PHONE#2-t 1 5 ZIl - Is 3 O PHONE # (ZiM J 3-1 " O ADDRESS Ito) clqk (-I A4. L *-+J R CROSS STREET OWNER OPERATOR 9C.,lrtll OIL PHONE 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.' jjjjjj DATE�U APPLICANT'S SIGNATURE �(M'1 � TITLE ��T��T��,, F[PLAN PROVED APPROVED WITH CONDITION(S) ❑DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) .�jJ�� ` tt -' DATE C/ / - IEWER'S NAME 1 M�^DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. r1 CONDITIONS: '� i- � s EH 23 046 (REVISED Uan Slav) CONTRACTOR INFORMATION TANK ID # AkC�jf) 39- a23 tG 3 v PHONE # Z�i 5 2 y - b53 CONTRACTOR NAME -nF CONTRACTOR ADDRESS '? O • o Io C � ) CA LIC # `/ P6D y CLASS R 2 C6( P✓ INSURER C LICoen m11Au.fanC-t cer d�WORKERCOMP# 39- FIRE DISTRICT 54 -PJ � LL 37"U W Lj"20P PERMIT# Uel CD iP%-S.i S� LABORATORY NAMEH 1n1f>O L COUNTY ST446LALAS PHONE# SAMPLING FIRM "� PHONE # - 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.' jjjjjj DATE�U APPLICANT'S SIGNATURE �(M'1 � TITLE ��T��T��,, F[PLAN PROVED APPROVED WITH CONDITION(S) ❑DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) .�jJ�� ` tt -' DATE C/ / - IEWER'S NAME 1 M�^DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. r1 CONDITIONS: '� i- � s EH 23 046 (REVISED Uan Slav) TANK INFORMATION TANK ID # TANK CONTENTS PRESENT & PAST DATE INSTALLED 39- a23 tG 3 v 39- 39- nTANKSIZE 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.' jjjjjj DATE�U APPLICANT'S SIGNATURE �(M'1 � TITLE ��T��T��,, F[PLAN PROVED APPROVED WITH CONDITION(S) ❑DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) .�jJ�� ` tt -' DATE C/ / - IEWER'S NAME 1 M�^DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. r1 CONDITIONS: '� i- � s EH 23 046 (REVISED Uan Slav)