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EIKIRONMENTAL HEALTH DEPART' NT APPLICATION F UNDERGROUND STORAGE TAIvXCLOSURE PERMIT THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: 9REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# PROJECT CONTACT IY1 r + 77 PHONE# ZS FACILITY NAME LVQ,{`C,/ O I PHONE# 2og 131-347 ADDRESS '-13 f"C ,00 OLc 5 IDG fart CZQ S- CROSS STREET i OLi "'t, OWNER OPERATOR lvrl2gy I PHONE# Z 09 93/ 7G 74 CONTRACTOR INFORMATION CONTRACTOR NAME C, C.G PHONE# 3'16- 61q- CONTRACTOR f -CONTRACTOR ADDRESS 0636 A L e4oj 6A 9q5 7 I CA LIC# GZZ 0q CLASS �� Z INSURER Yh e►1 j j d WORKER COMP# L'? 1 Y7DY FIRE DISTRICT PERMIT# LABORATORY NAME T I-- COUNTY w.< PHONE# -5-7'1-. /9 SAMPLING FIRM V rt PHONE # ?D TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED fAeSos, 39- 13 1v L q (Aj 15-1,000 r Q a ,*o 6're— (A Kos-,- 39- L q3-Pr d0o 'v-w. llrt c 39- 39- 39- 39- Ki N �SSOQ v r c ✓C N�/i/ APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, FEDERAL LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I 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 TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I 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.." v Co'" `� I 9:;V ill APPLICANTS SIGNATURC/1 TITLE ! d�t C' Aa NAC G✓ DATED ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME U, DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046(REVISED 10/16/03) Page 3 1. (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES[] NO []