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s F-, • ,....,.. <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 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> % REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSU. K LACE <br /> Mmw <br /> s ._ <br /> EPA SITE# PROJECT CONTACT 5 c-m c I PH. �?; _ " <br /> FACILITY NAME j=,.< / <br /> -�z <br /> ADDRESS fj <br /> CROSS STREET Q V-w•Lw►1ti" <br /> OWNER OPERATOR 1. L L S PHONE#ZOi;]•' 3''i".=;; ;. �i'1" <br /> -- — <br /> CONTRACTOR NAME vL C a 11PHONEf S30 -&78' -(99-34 ' <br /> CONTRACTOR ADDRESS `U: Bch G64 CA LIC# 4'r-?Z7, CLASS <br /> INSURER WORKER COMP# •d <br /> FIRE DISTRICT i PERMIT# O'Ek - 5y l <br /> LABORATORY NAME COUNTY O L PHONE# ,30 29"1-4k W <br /> SAMPLING FIRM c G PHONE# cit <br /> _ _ <br /> Ah l.._ <br /> TANK ID# TANK SIZE TANK CON _- ENT AND PAST DATE INSTALLED <br /> 7777... <br /> �- <br /> - " - <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN E ATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP. 1 i1�GENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR yw j NOT EMPLOYIUVY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION, bR JMRIJN(i Of SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FO OWING: 'l CERTIFY THAT IN THE PEOICH 1$PERT�ft IS-`ISSUED, 1 SHALL <br /> EMPLOY PERSONS SUBJECT TO ORKER'S COMPENSATION LAWS OF CALjFCfRII ' " --- <br /> APPLICANTS SIGNATURE b l�LILL, TITLE'(ec�uF�,.- DATE-t -I a-O-i' <br /> �7 APPR ��: _1! 'PI € Cl # � ,� APQROEC <br /> .77 <br /> NDITILI EI SAF 4LVE1/EJi�QI�X TA�iMENT� <br /> _ f <br /> PLAN RVWEt`S NAA+ DATE �� <br /> 1 OS <br /> ANl'OV1AI� 1=1OMM PIIS AL> ittU „T` � � NLtOIt�gtpl.PI�tRT{7 GifIIMENaINGillitfK. <br /> MI <br /> rtY� <br /> :. _, ..: <br /> _ <br /> EH 23 046 (Revised 07/31/08) 3 <br />