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1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> t9LREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# 'W ?)US I PROJECT CONTACT ek PHONE#610q W(P 0 3 <br /> FACILITY NAME TOG ik I-1I PHONE#LOU 2 0121 35&1 <br /> ADDRESS 1250 N- W 1 Z-Q 1 V � <br /> CROSS STREET H GI <br /> OWNER OPERATOR 1\ PHONE <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME I PHONE# alb (LOID (p�ZZ <br /> CONTRACTOR ADDRESS 5 �I I I CA LIC# CLASS <br /> INSURER WORKER COMP# qD IIPIP3' LO13 <br /> FIRE DISTRICT L N PERMIT# <br /> LABORATORY NAME IrW V2' c^• COUNTY cl -l(-1�I- G <br /> SAMPLING FIRM PHONE# <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39- 3`I I c� b00 0\50 iv­e— <br /> 39- I m ty' L I q616 <br /> 3s- 35 u I <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 ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS 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 <br /> EMPLOY PERSONS SUBJECT TO WOR 'S COMPE//N/SA�TI N`LAWS OF CALIFORNIA." ,p� <br /> APPLICANT'S SIGNATUR `6�c S� —TITLEDATE-4Z <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> EE CONDITIONS BELOW AND/OR ON AT PA T] t tr <br /> PLAN REVIEWER'S NAME DATE I p 26l <br /> ANY DEVIATIONS FRO THIS P LICATI MUST BE SUBMI TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046 (Revised 10/30/12) 3 T-0 I <br /> -OI I <br />