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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 ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE PROJECT CONTACT PHONE# ii1 - -al iJ-(y� <br /> FACILITY NAME G C Cl 1PHONE# <br /> ADDRESS tot- <br /> CROSS STREET <br /> OWNEROPERATOR Ci -lZI!ejreUyrlPHONE* Zoq <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAM Z t _ PHONE# S-WZ�•-HTB <br /> CONTRACTOR ADDRESS f •©, jtp AU C- CA LIC# Z CLASS/�• Z <br /> INSURER �L_ WORKERCOMP* <br /> FIRE DISTRICT Sr(:> rl PERMIT# <br /> LABORATORY NAME jL� COUNTY PHONE# SSO -'2-q - Roo <br /> SAMPLING FIRM C PHONE# <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> l � 39-USI' icloo la " A' b'-t IL-L4 OWO <br /> 42- <br /> 2 939 poo �� .ocut, L2u �I owti <br /> 3 - <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THEF OWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT T RK=CMP�BATION LAWS OF CALIFORNIA,' <br /> APPLICANT'S SIGNATURE TITLE f�6WT{roLG v DATE [ 8-og <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> ( ONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE "1/� <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046 (Revised 07/31/08) 3 <br />