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SAN JOt COUNTY PUBLIC HEALTHr0ICES <br /> LAVIRONMENTAL HEALTH DIVISI .. <br /> APPUCATION 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 90 DAYS FROM THE APPROVAL DATE 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# L] - PROJECT CONTACT - PHONE# <br /> FACILITY NAME - LI� PHONE# <br /> ADDRESS-- C <br /> CROSS STREET <br /> OWNER OPERATORR C PHONE 1 - SA041 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAMES" G - V - PHONE - <br /> CONTRACTOR ADDRESS S i E 0 -5 C 76MC CA UC#7 CLASS - <br /> INSURER C W WORKER COMP# - -1 <br /> FIRE DISTRICT U\ PERMIT# <br /> LABORATORY NAME rj= t COUNTY PHONE <br /> SAMPLING FIRM J - PHONE It ( -7 _ L) <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE T CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39— c� <br /> 39- <br /> 39— <br /> APPUCANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS. FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING. 'I <br /> 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 <br /> TO BECOME SUBJECT TO WORKERS COMPENSATION LAWS OF CJUJFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CAUFORNW* <br /> APPLICANT'S SIGNATURE'---� <br /> ❑ APPROVED EVAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> �// �(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> Z '�--;j ��--r'�! DATE <br /> PIAN REVIEWER'S NAME `��� 1� r <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br />�,f t^-2 nee/npnilc- 1 1nil njMf'v <br />