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ENVIRONMENTAL HEALTH DEPARTMENT 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 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# PROJECTCONTACT LF1 PHONE# -f/s FACILITYNAME /{ L/ z- JZ,p,,�/ UR/Q�c PHONE# ADDRESS IO W14, c 9S�3G CROSS STREET �O/L�✓Fiz ZGIf �rJ1Flr OWNER OPERATOR PHONE# ,f CONTRACTOR INFORMATION CONTRACTOR NAME 1 PHONE# CONTRACTOR ADDRESS CA LIC# I,6OS0 CLASS L/ INSURER WORKER COMP# FIRE DISTRICT Pr7`./L / PERMIT# /y- gp LABORATORYNAME %L. COUNTY HONE# qy S, SAMPLING FIRM LQ - a "1 PHONE# TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PA DATE INSTALLED 39- n- 400 c-,L nK,F --'A/44V o/L !/•vlcr-Yi4iai o oi' 39- 39- 39- 39- 39- APPLICANT 9-39- 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS OF CCAL'IFFOORNIA' APPLICANT'S SIGNATURE ,/C%�(/`Lz7, �TITLE�IY�-rntf Srro./Y!R DATE 9-a-1 ❑ APPROVED gAPPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS F M 11LLICATON MUSTE BMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK VONDITIONS: EH 23 046 (Revised 07/17/14) 3