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SAN,' \QUIN COUNTY PUBLIC HEALTF=RVICES "ENVIRONMENTAL HEALTH DIVISZI N 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: V/REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE #C/? a a- 611 PROJECT CONTACT LDLL. PHONE# FACILITY NAME hI PHONE # ADDRESS 7.'S� CROSS STREET OWNER OPERATOR PHONE # TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENTS PAST) DATE INSTALLED 39- (np,K 1 39- 39- 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 AGENTS 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.' APPLICANTS SIGNATUREA(�/_TITLE ❑ APPROVED APPROVED WITH CONDITION(S) ❑ CONTRACTOR INFORMATION (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) CONTRACTOR NAMEj- L- fa n PHONE # / % -1 CONTRACTOR ADDRESS (O"1'IJ CA LIC # 7 CLASS {. / INSURER WORKER FIRE DISTRICT ') .�/ f., PERMIT # LABORATORY NAME COUNTY PHONE # ` _ SAMPLING FIRM 6jpn1ZV1p01 PHONE It TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENTS PAST) DATE INSTALLED 39- (np,K 1 39- 39- 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 AGENTS 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.' APPLICANTS SIGNATUREA(�/_TITLE ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME G�'%� � DATE /3 -Aj ANY DEVIATIONS FROM THIS APPLJCATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: -=X"i rr"),] 3j5 ~Azv--�Z> A-...,enla ti i = — ti,=T sJoC4r15;Q D2 TrL7E /i4 G�.r/ g : !r/GQT^- • Sr1Q/�: TGA r"i � TiG ti T !S O.�Fi� EH 23 p046 (REVISED 10/1 /98) Page 3