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SAN JOIN COUNTY PUBLIC HEALTH SOVICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTlTEMPORARY 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: REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# t296Z 2°112, PROJECT CONTACT PHONE# ,$ i FACILITY NAME • 1. A G PHONE# ADDRESS CROSS STREET OWNER OPERATOR C LAA Collcw PHONE#709- CONTRACTOR CONTRACTOR INFORMATION CONTRACTOR NAME PHONE# CONTRACTOR ADDRESS CA LIC# J;TO I CLASS INSURER G WORKER COMP# FIRE DISTRICT PERMIT# LABORATORY NAME G $ COUNTY PHONE# SAMPLING FIPHONE RM TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED 39- a'mo efts 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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 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: -1 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:" APPLICANT'S SIGNATURE k I TITLE .PGdI DATEIZ .�'D�/ ❑ APPROVED PPROVED WITH CONDITION(S) ❑ DISAPPROVED n (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME--�� (�{ DATE 5j/j0 ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046(REVISED 08173/99) Page 3