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Oct 09 06 09:55a A R EreTeering <br />�Asf <br />yjQ�l <br />818842376th P•3 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN 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�TAANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />p4 REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />FACILITY INFORMATION <br />-7-777717 <br />CONTRA CTORINFORMATION ' <br />E <br />>, <br />PHONE ' <br />CONTRACTOR NAM <br />Z �- 6 <br />Z CA LIC # CLASS d <br />CONTRACTOR ADDRESS <br />A <br />n] <br />WO� �G <br />ORKER COMPO <br />INSURER <br />FIRED! STRICTG <br />�/J <br />l^�IQ.R'R CA I Kt�6 <br />PERMIT # <br />LABORATORY NAME <br />A"a Tlc-^L- <br />COUNTYSQ A PHONE <br />SAMPLING FIRM ip <br />PHONE <br />_ � TANK INFORf•IIATION _ - <br />TANK IU # TANK SIZE TANK CONTENTS (PRESENT 8 PAST �Q nEINSTALLED <br />39 $I I � oo� I A �l A `lb <br />39- 0 S 8; o0o V 1 `12 <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 ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S 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 <br />CERTIFIES <br />TL IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />PERSONSEMPLOY SUBJECT TO WORKER'S COMPENSATION N <br />I APPLICANT'S SIGNATURE <br />TITLE <br />APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />77. <br />ISEE CONDITIONS BELOW AN /OR ON A AGHh1ENT) <br />PLAN REVIEWERS NAME___- yam` DATE <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIORTO COMMENCING WORK <br />CONDITIONS: <br />EH 23 046 (Revised 9/9/06) 3 is <br />