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SAN J UIN COUNTY PUBLIC HEALTH *VICES ENVIRONMENTAL HEALTH DIVIS10M 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: X REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE CONTRACTOR INFORMATION FACILITY INFORMATION EPA SITE # PROJECT CONTACT PHONE ZO34 %� FACILITY NAME I PHONE 'z ADDRESS INSURER A4togt> - t% -W (q MM CROSS STREET WORKER COMP# 'r -- PERATOR 1-4VyCLACC,7 FeAp YQ. Al PHONE ZL32 - CONTRACTOR INFORMATION CONTRACTOR NAME TU77COE-,Aj 11& iLf }L / 11 PHONE Q4 CONTRACTOR ADDRESS A) 1414Z I CA LIC 2Z-7 CLASS INSURER A4togt> - t% -W (q MM ArS�.Uc, • WORKER COMP# 'r -- FIRE DISTRICT (in a6tFAFVkaJ77&Z 39- PERMIT # LABORATORY NAME A -LP COUNTY PHONE VIE ��j SAMPLING FIRM p PHONE ii 40-64cl 1 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 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 L6CENSED 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 FOLLOVONG"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 C.LLiFORN A.` _--) I/ APPLICANT'S SIGNATURE _ TITLE Z; Z40/ /[SATE ❑ APPROVED NYAPPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDIT#ONS BELOW ANDIOR ON ATTACHMENT) PLAN REVIEWER'S NAME(, 1 I Ccs .�� 1� I_ �f �? _3 DATE I ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. C ONDITIONS- EH 23 046 (REVISED 10119198)