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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE NK(S PRIES 180 DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> EMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EP SITE PROJECT CONTACT PHONE# + 9-r-43 <br /> FACILITY NAME cX A PHONE# <br /> ADDRESS - LAF. <br /> CROSS STREET F <br /> OWKER TORj PHONE#• <br /> CONTRACTOR INFORMATION <br /> CO,TRACTOR NAME S-" 2PHONE# <br /> CO TRACTOR ADDRESS CLb CA LIC# f�� CLASSC 6( Z <br /> INS RER WORKER COMP* <br /> FIR DISTRICT PERMIT# <br /> LA RATORY NAME ` - OUNTY ;HONE* <br /> SA PLING FIRM - PHONE# <br /> 4iL Y-- <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAS DATE INSTALLED <br /> 39 Ec <br /> 39 c/Z <br /> 39ir <br /> 39 <br /> 39 <br /> 39 <br /> AP (CANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> RE ULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING 'I CERTIFY T T 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 BECO �D6J ER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES TH LO ING: 'I CERTI E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJE O ER'S MPENSATION F CALIFORNIA.' <br /> AP LICANT'S SIGNATUR TITLE /JAEtE-, DATE6 I/ 6 <br /> APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> P N REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH2 046 (Revised 12/31/07) 3 <br />