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06t 09 06 09: 55a A R EnItering 8188423760• 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,TANK(S)EXPIRES BO DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> TA <br /> J 1 REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> IfMCILI.TY INFORMATION <br /> .r.PROJECT CONTACT A V T <br /> EPA SITE#OAl.D 00 y' PHONE# 5 � .�'' <br /> FACILITY NAME WQ -r= Z-=� <br /> ADDRESS -4-140 S <br /> CROSS STREET A L-4t ZT PHONE CI'E�' 1 <br /> OWNER OPERATOR VL � <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME PHONE b <br /> klm <br /> CONTRACTOR ADDRESS S b V -L- � Z IF LIC# CLASS Q <br /> INSURER A nJ WORKER COMP# <br /> FIRE DIST rnC^Tj CA I�rc. PER # <br /> LABORAT IF I N IJ, lZilltA>,neo. Tl«(-- COUNTVSCI A PHONE 297"q'8O0 <br /> SAMPLING FIRM PHONE <br /> ttavu�N t Rib �t - 10 <br /> TANK'YNFORMATI ON <br /> TANK ID41 l ANK SIZE TANK CONTENTS(PRESENT& PAST) �Q ATS STALLED <br /> un1 L a <br /> 39- SV ols 92 clb <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 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAW kOF CALIFORNIA.' (�,, <br /> APPLICANT'S SIGNATURE `` `v -TITLE r'Y3Z-��DAT <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AN IOR ON AOHIIIENT) rf p <br /> . .DATE <br /> PLAN REVIEWERS NAMEL'Vim- <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO END.FOR APPROVAL PRIORTO COMMENCING WORK <br /> CONDITIONS: <br /> EH 23 046 (Revised 819/06) 3 �$ <br /> A <br />