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ENVIRONMENTAL HEALTH DAARTMENT SAN JOAQUIN COUNTY 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: __" T�.fiOnOAOV I'I 11CI IRP n CLOSURE IN PLACE Li REMOVAL IJ ' """ W."., -- - - FACILITY INFORMATION EPA SITE # PROJECT CONTACT PHONE# CONTRACTOR NAME PHONE # FACILITY NAME 39- ADDRESS WORKER COMP# CROSS STREET 39- FIRE DISTRICT PHONE# OWNER OPERATOR COUNTY PHONE # TANK INFORMATION CONTRACTOR INFORMATION 39- PHONE # CONTRACTOR NAME CA LIC # CLASS CONTRACTOR ADDRESS 39- WORKER COMP# INSURER 39- FIRE DISTRICT PERMIT # LABORATORY NAME COUNTY PHONE # SAMPLING FIRM PHONE # TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- 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 ENVIRONMENTAL HEALTH DEPARTMENT, 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 SUBJECT TO SIGNATURE CERTIFIES CTHE E WORKER'S FOLLLOWING 'I CERTIFY THAT PIN THE IPER PERFORMANCE OF TON LAWS OF HEWORKCONTRACTOR'S IR WORK FOR WHICH THIS IS ING OR IISSUOED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE TITLE DATE FFANYDEVIATIONS D ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) DATE ME FROM THIS APPLICATION MUSTBE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 11/21/06)