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E*ONMENTAL HEALTH DEPARTMENO APPLICATION FOR UNDERGROUND STORAGE TANK CLOSUPE PEPU T l"TILS PERMIT FOR PERMANENTffeMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUU5TANCES STORAGE TANKS)EMPIRES I)0 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: REMOIYAL ❑ TEMPORARY CLOSURE CJ CLOSURE !N PLACE FACILITY INFORMATION .��.,�,. PROJECT CONTACT 1'(" ^uCitJ{p�IQI' PHONEf12..Oq." a`%.F"". F.ACIG'TYNAM€ 71)Cr 7 UE'I Cerin PHONEY -7-C f?Z p6�z•^ pADDRFGS k3f,!f LIr496E`iFi'N Cdr QyZ.b6 CROSS S?F'zEf Via.jw WIS�pm COJ. T- �'-- OWNER OPERATOR I O:i� CONTRACTOR INFORMATION �� m i'CONTRACTnR NAME f �,}+ P (� +�PpH2ONE/�Y .`".d� gi500 GOPdT,?AGTOR ADDRESS �b k. nl `�Sb�b CALIC* I;, C&I& I CLG,SS YI INsuRER &,N pNt 4 ' p} LV L4 c--s WORKERCOMP# •'LTpQ p , 1 � -` � y MFIRF DISTRICT Eo ' iJRATORY NAM'c T r\gJvSQN EDW( COUNTY SPrN 4CA112 W I PHONE t p ,'±Mf INC-FIRM jfets.0, C-- PHONE 4 yo 9 3 6 c t L 2.G�1 • �'fi T• 1£+ j TANK INFORMATION _ TANK iD TANK SIZE TANK CONTENTS PRES NY& PAST DAME iNBTALLEO 39- 39- APPLICANT MUS7 PSRFORM AL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.FEDERALLAWS.AN?RULES AND +ie REGULATIONS OF SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH OEPARTMENT, OWNER OR UCENSED AGENT$ SIGNATURE GERT;FIES THE FOL:LCIMNO; •1 PER NFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 15stim,I St ALL NOT EMPLOY ANY P::3!30.IN SUCH 1 A MANNER AZ TO S'cCOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CAUFORNIA: CONTRACTOR'S HIRING OR SUSCOtv'TPAOTING 3 SI;'aNATUR W OERT!FIES TrIE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMP i51,3 EU,I SHALL EMFIAY p PERSONS SUSJEGTTOWCP•KER'S COMPs1SATION LAWS OFCAUFORNIA.• E _ _-- FtPFLIGA!t7'}SIGNAT UrC -DATE -'-f p j EI APPROVED ;<APPROVED WITH CONDITION(S) 0 DISAPPKO'i/ED (SEE CONDITIONS 5E OW AND/OR ON ATTACHMENT) p1 PLAN RZ14EV,E R'S NAM- - . . DATE 'Asp ANY DEWC.TION'S FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCENC CRK- CONDITIONS: EH 23 948!P.!=t.'ISED10/iblDi) Page 3 Is/ _. 11 Lo Erere a EEM contactor's and subcontraclDr s questionnaire or file or endosed-' YFR 110.;