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SAN JCRUIN COUNTY PUBLIC HEALTH VICES <br /> VIRONMENTAL HEALTH DIVISI <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> W!rEEMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE PROJECT CONTACT c S PHONE# <br /> AL-W- F, <br /> FACILITY NAME t� " PHONE# <br /> ADDRESS / ( v SC E 04' - C .S Q `� <br /> CROSS STREET l_LG('0 Wi l' <br /> OWN[ AERATOR �( 1 PHONE <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME PHONE# - <br /> CONTRACTOR ADDRESS O L&llog `- T��Y- 1� CA LIC# <br /> INSURER1_E �' tt ?� WORKER COMP# 0 <br /> FIRE DISTRICTS PERMIT# <br /> -HONE# C-' �-? <br /> LABORATORY NAME ter. (� .0 COUNTY, <br /> SAMPLING FIRM lli[ F^a r-le4la PHONE= 47""'i {1 - I Cf% <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- - _ / p .. oto. <br /> 39- <br /> 39- <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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "i <br /> 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 <br /> TO BECOME SUBJECT TO WORKER'S COMP kSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HfRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERT{ FORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION OF ALIF Ittvw_" <br /> APPLICANT'S SIGNATUR <br /> - TITLE qE:9�r_ DATE <br /> [I APPROVED APPROVED WITH CONDITION(S) [3 DISAPPROVED <br /> (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME 6 DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL.PRIOR TO COMMENCING WORK. <br /> fONDITIONS: <br /> Z _ 4- <br /> If <br /> EH 23 048(R ;119 <br /> Page 3 <br /> , <br />