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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 TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION _ <br /> EPA SITE# PROJECT CONTACT LOC 1n WJ CSS- PHONE r + ;Z���vsi;ILI <br /> I <br /> FACILITYNAME c c - r - PHON x. <br /> ADDRESS '16L�? <br /> CROSS STREET 1 ©`V'tA� �bti �f 15inti 7 <br /> ' OWNER OPERATOR L L Li`- L S PHONE#'L0c1 '�1l'"i!�'j 47 <br /> CONTRACTORINFORMATION <br /> CONTRACTPHONE# S'0 -67_ -6E3 <br /> CONTRACTOR ADDRESS Sp � CA LIC# CLASS 4-H>?-Z <br /> INSURER -(4 WORKER COMP# _ •O Ff <br /> ' FIREDISTRICT i PERMIT# 08 - 5 <br /> V1 <br /> LABORATORY NAME . COUNTY O I PHONE# -10-1-9-1 <br /> SAMPLING FIRM r. � r - PHONE# G I L_ <br /> 1 3 <br /> ' TANK INr— OK <br /> TANK ID# TANK SIZE TANK CONTENTS fPRESENT AND PAST DATE INSTALLED <br /> 39-0,Y5 In ow <br /> 'I 39 <br /> 39- <br /> 39 <br /> �I 39 - <br /> 39- .= <br /> x tt :,, <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN - , <br /> LAWS.FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP Y. AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WH 'HALL NOT EMPLOYA14Y PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LA ¢LC*:WHICH' HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FO OWING: 'I CERTIFY THAT IN THE PERF C.00,. ORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL <br /> EMPLOY PERSONS SUBJECT TO ORKER'S COMPENSATION LAWS OF CALIFORNIA' <br /> APPLICANTS SIGNATURE I)U, TITLE DATE /I-(8 -0� <br /> APPROVED A.APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> NDITID FLOW ANDJOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAMF /� - DATE. <br /> ' ANY DEVIATION$FROM THIS APPLICATION MUSTBe SUBMITTED TO EHO FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> ' EH 23 046 (Revised 07(31(08) 3 <br />