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2 <br />y <br />7 <br />i <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENTITEMPORARY 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 />.REMOVAL n TFMDnD A DV M ^01 IMM I <br />rANKINFOAMA- TION <br />TANKID# TANK SIZE TANK CONTENTS PRESENT AND.PAS DATE INSTALLED <br />� .I ' Acl o O /E E Z <br />38- O 115&1 �Z a o00 />/�StL 9 <br />39-P o vZ 0 000 D/E 46 7,z <br />3"9 <br />39.Q. S o! w a000 511,7 i ocV d eAf0E, loc1� q Z <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: N CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />EMPLOY PERSONS SUBJECTTO WORKE;MCOMPENSATION LAWS OF CALIFORNIA' _ <br />po <br />APPLICANTS SIGNATURE "' _TITLE_ OG.//•�/� 6400 DATE <br />i <br />(SEECONDITIONS-B LOW' NDDIORONATTACRM <br />PLAN :REVlEWER'S-::NAME _'��� �'A L� ? AT <br />ANYDE,VIATIONS FRO iHI3A PCICA.N MUST BE SUBMI ED.TO H F R PROVkL I ,TO: -MM NCI R; <br />CONDITIONS:: . <br />EH 23046 (Revised 10/30/12) 3 <br />FgG1LITY INFOFWATION <br />EPA SITE#CAV 1794 <br />QV -1 PRn.IPr.TrnNTACT <br />URPE <br />I PHONE#mac/ ZS % <br />FACILITY NAME Jr <br />'/� <br />/.S 6 / <br />PHONE#LOy <br />ADDRESS / <br />CROSS STREET <br />/4 - <br />OWNER OPERATOR <br />A <br />G <br />PHONE#LCJ 7 J <br />_ <br />rANKINFOAMA- TION <br />TANKID# TANK SIZE TANK CONTENTS PRESENT AND.PAS DATE INSTALLED <br />� .I ' Acl o O /E E Z <br />38- O 115&1 �Z a o00 />/�StL 9 <br />39-P o vZ 0 000 D/E 46 7,z <br />3"9 <br />39.Q. S o! w a000 511,7 i ocV d eAf0E, loc1� q Z <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: N CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />EMPLOY PERSONS SUBJECTTO WORKE;MCOMPENSATION LAWS OF CALIFORNIA' _ <br />po <br />APPLICANTS SIGNATURE "' _TITLE_ OG.//•�/� 6400 DATE <br />i <br />(SEECONDITIONS-B LOW' NDDIORONATTACRM <br />PLAN :REVlEWER'S-::NAME _'��� �'A L� ? AT <br />ANYDE,VIATIONS FRO iHI3A PCICA.N MUST BE SUBMI ED.TO H F R PROVkL I ,TO: -MM NCI R; <br />CONDITIONS:: . <br />EH 23046 (Revised 10/30/12) 3 <br />