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SAN JOAN COUNTY PUBLIC HEALTH SO'ICES ENVIRONMENTAL HEALTH DIVISION 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' REMOVAL ❑ TEMPORARY CLOSURE CLOSURE IN PLACE FACILITY INFORMATION ,� EP ITE PROJECT CONTACT PHONE# I, Y NAME PHONE# �+ ADDRESS Q D D CROSS STREET F' - OWNER OPERATOR PHONE# 9 46 CONTRACTOR INFORMATION CONTRACTOR NAME L, `, PHONE# C o ADDRESS L V ` A LIC# CLASS ZBORATORY T RKER COMP# ` N E SCOUNTY PHONE# ," Z 0 PHONE p JXXY TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED 39- pa3 1 44 62 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 LICENSED AGENT'S 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 FOLLOWING, 'I CERTIFY THAf IN THE PERFORMANQE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWOF'CALIFORNIA.' APPLICANT'S SIGNATU TITLE �M M- DATE v ❑ APPROVED 9 APPROVED WITH CONDITION(S) ❑ DISAPPROVED 7 I� (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) .�l PLAN REVIEWER'S NAME� A /�� DATEL Lq ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: O a _ - c ) e�Fp �x GYiZtiL J`Um! �° Ca°,>° �,wuaawlt i EH 23 046(REVISED 08/13/99) Page 3