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SAN �,,,,4QUIN COUNTY PUBLIC HEALTI,,fERVICES <br /> ENVIRONMENTAL 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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECTCONTACT < c[��/=AFF y_ PHONE# •� <br /> FACILITY NAME G Cps <br /> ADDRESS Q e�I/' ",/=c <br /> CROSS STREET G G <br /> OWNER OPERATOR _O PHONE# 3 <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME �- /[ .If'�, PHONE#� <br /> CONTRACTOR ADDRESS �. CA LIC# 6' CLAS <br /> INSURE /wIT d [ S WORKER COMP# A .-p <br /> FIRE DISTRICT Cl T ' .S PERMIT# C o-°&9.7 h�i2pt/ L <br /> LABORATORY NAME / [ COUNTY „/ .If I PHONE#10 9S 7Z 0 <br /> SAMPLING FIRM gdd&gff PHONE It 20 O <br /> TANK INFORMATION <br /> I -- TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 3 - - <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 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 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THEPEgFjFFORMANCE OF THE RK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIF FHf <br /> APPLICANTS SIGNATUREA TITLE ���C�C�©/� DATE O <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON AT7ACHMENT) -7 <br /> PLAN REVIEWER'S NAMEDATE <br /> ANY DEVIATIONS F 1HIS APPLICATIO//N MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> i <br /> EH 23 046(REVISED 10/19/98) Page 3 <br />