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7{i = 4 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAIQUIN COUNTY <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANKS) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS INDICATE PERMIT TYPE: <br />REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />A, <br />APPUCANT MUST PERFORM ALL WORK 1N ACCORDANCE WMTH' SAW JOAgU W COUNTY ORgHANCGb, STATE LAWS, FEDERAL LA' <br />RECiUTI0N9 OF SAN JOAQUIN COUNTY ENVIRONMENTAL II EALTM DEPARTMENT OWNE0. OR LICENSED AGEFIT'9 SIGNgTµD RULES AND <br />TOLLOWNO, I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FO RWHICHTHISFERMITIS ISS ED,I M URE CERTIFIES TME <br />A LUNNER AS TO EGCOMG SUBJECT TO WORKERS COuxu¢Arnu ,.,... .... U S ALLNOT ENPLOr <br />IES THE FC <br />SUBJECT 70 <br />APPLICANTS SIGNATURE <br />PLAN REVIEWER'S <br />!C3' AT N THE PE OR— CF THlR� UONiRACTOR'S MIRING OR SUSCONTRACTWC <br />WORK EOR WHICH THIS PERMIT IS ISSUED. I SMALL <br />nnw.� TITLEPROV D WITH CONDITIONS) ❑ DISAPPROVFT) <br />ANY DEVIATIONS FROM TNIS APPLICATION <br />DATE��u�O� <br />SUSMTRED TO END FCR APPROVAL PR10R TO COMMENCIN WORK, <br />ONDITIONSI <br />-LhJ1✓1I� � LJ(J41 cen� 1"A I )A I I/' - <br />EH 23 046 (Revised 9/9/06) 1 <br />