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SAN JOA JIN COUNTY PUBLIC HEALTH SL DICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FO PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TAN )EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: EMOVAL ❑ TEMPORARY CLOSURE Cl CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# ]Z? PROJECT CONTACT - PHONE# FACILITY NAME I - PHONE# ADDRESS L 1 C I 1 CROSS STREET 1 OWNER OPERATOR _ �� C i IPHONEA01 CONTRACTOR INFORMATION CONTRACTOR NAME �, L �— la_ v PHONE �s CONTRACTOR ADDRESS o S i E E - 570c- i ON CA LIC CLASS - �I INSURER - I WORKER COMP# U - FIRE DISTRICT 1= \ ;� % - Z PERMIT# LABORATORY NAME'S= COUNTY PHONE / 5 U 00 SAMPLING FIRM J PHONE TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED 39- 39- �- 39- u no n _ N 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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: -1 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: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.* APPLICANTS SIGNATURE ;'-� G TITLE�r�-j�1 i F Uig U��Nth DATES �� ❑ APPROVED &KPPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DA �/ ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDI IONS: lz"All EH 23 046(REVISED 10/19/98) Page 3