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rSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTfTEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> ' STORAGE TANK(S) EXPIRES 90 BAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE <br /> REMOVAL 0 TEMPORARY CLOSURE CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> cP TE PROJECT CONTACT P�IONE# `p _ 3GI <br /> Y NAME IPHONE# <br /> ADDRES <br /> YA"f)lu D + <br /> CROSS STREET �F <br /> OWNER OPERATOR [j PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME I , PHONE# `� rj <br /> C C ADDRESS L A LIC# K l-cLAsS <br /> /\.. SURER RKER COMP# <br /> BORATORY N E COUNTY PHONE# <br /> PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 44 62 <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT <br /> 9- <br /> 39- <br /> 39-39_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 AGENT'S--&IG7JRYURE CERTIFIES THE FOLLOWING 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED .HAL�TNOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONT TOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING 'I CERTIFY TH IhJ TH E OF THE WORKFOiZ4VHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TC <br /> WORKER S COMPENSATION LAW ALIFORNIA, �, <br /> APPLICANT'S SIGNATU TITLE _DATE <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW ANDFOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAMEA DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> k. O-,,, <br /> ` a <br /> cola <br /> EH 23 046 (REVISED 08!13199) Page 3 <br />