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SAN <br /> JOAOOIN COUNTY is <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS STORAGE TIANKQ(S EXPIRES 90 DAYSORARY FROM THECLOSURE <br /> LDATE. DO NOT BANDNMENT IN PLAEWRIECN ANY SHADED UNDERGROUND <br /> AREAS N, DICATE PERMIT TYPESUBSTANCES <br /> ❑ REMOVAL 4 TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT �j- PHONE# y0$ Y� X74 <br /> FACILITY NAME PHONE# gos -69t7- Uv�7 <br /> ADDRESS 7 I C/ <br /> CROSS STREET <br /> PHONE <br /> OWNER OPERATOR <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME "Ir t?.t PHONE# 751 J40 <br /> CONTRACTOR ADDRESS �d ri t{� G CA LIC# 737,36 CLASS <br /> YNSURER d WORKER COMP# C7i'�7 0'®'O <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME COUNTY PHONE.# <br /> SAMPLING FIRM r PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- 1 ooO <br /> 39- <br /> 000 <br /> 39- 00 r 7 <br /> L <br /> - <br /> - <br /> - <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 ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY <br /> PERSONS SUBJECT TO WORKER'S COMPENSATIO LAWS OF CALIFORNIA" <br /> APPLICANT'S SIGNATUR TITLE 't DATE <br /> ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW ANDJOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE _ <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046(REVISED7/2$106) Page 3 <br />