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SAN Jr F UIN COUNTY PUBLIC HEALTH I 0 ;VICES <br /> `�NVIRONMENTAL HEALTH DIVISII`� <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTIT'EMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCI <br /> STORAGE TANK(S)EXPIRES 90 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# Z 2. PROJECT CONTACT v PHONE# 630- ^L> <br /> FACILITY NAME s PHONE# 3 <br /> ADDRESS I S a I U I- L <br /> CROSS STREET t <br /> OWNER OPERATOR tM Cl CIO <br /> PHONE# - 2— <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAMPHONE# - <br /> CONTRACTOR ADDRESS _ . CA LIC# CLASS <br /> INSURER t WORKER COMPO <br /> FIRE DISTRICT s PERMIT# <br /> LABORATORY NAME L.,n. COUNTY PHONE# 6 <br /> SAMPLING FIRM PHONE II <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- i -.-z <br /> 39- - o3 1 i 7 <br /> 39- <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 PUBLIC 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.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKERS COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SWILL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS CALIFORNIA.' <br /> APPLICANTS SIGNATURE TITLE C ztj,,j .ckpir DATE j1_�-01 <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT? <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM.THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> I)/ ;wft/ � r0 R <br /> t (7 I,�/. ��v rl ?-n I ZI77 { <br /> lo - <br /> JJ'r��' /�c r tv�C\ Cit <br /> --m ^1 fA l <br /> EH 23 0046(REVISED 10/19198)13 /12 <br /> �)/ 1 mIYT(M, �Y q !/l/C�' L IJ/_ lL�r-/lC���iYlf �✓tiC <br />