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ENVIRONMENTAL HEALTH DEPARTMENT APPLICATION F UNDERGROUND STORAGE TA- CLOSURE PERMIT THIS PERMIT FOR PERMANENT/TEMPORARY 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: REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT & PAS DATE INSTALLED 39- C 3� L 3 0 0o r uciccl aso !� r� I 39- 3 - P DOD lirt c 39- 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 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, 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: "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.' 4;,V, r 62. APPLICANTS SIGNATURE O-" fitcll TITLE i I l e A4 M,44 e-6- DATE 6fo-?6e,51 ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME 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) oa o (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES [ ] NO [ ] FACILITY INFORMATION EPA SITE # PROJECT CONTACT a '/1 M + PHONE# `[ 16 - - G ( ZS FACILITY NAME LV 4.+Ic✓ O :56CjIf I PHONE # 244- .0 .-ADDRESS ADDRESS315 4Jv,- -00 K6aef, - %DL id-" CA 57 CROSS STREET i OL i D-4T� LABORATORY NAME T I-- OWNER OPERATOR /t,'c,29y I PHONE # Z 09 93i c�G 7Z4 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT & PAS DATE INSTALLED 39- C 3� L 3 0 0o r uciccl aso !� r� I 39- 3 - P DOD lirt c 39- 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 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, 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: "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.' 4;,V, r 62. APPLICANTS SIGNATURE O-" fitcll TITLE i I l e A4 M,44 e-6- DATE 6fo-?6e,51 ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME 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) oa o (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES [ ] NO [ ] CONTRACTOR INFORMATION CONTRACTOR NAME ` I PHONE # 5 IG- Ig- 13 e) CONTRACTOR ADDRESS 1163(. A Lr•6r+d qq 77CA LIC # G7? OQ I CLASS A- 14,+L INSURER rn �� v Pd WORKER COMP# t l Y70 `/ FIRE DISTRICT (4V 3joCfe-'40-, PERMIT # e--' 4 !v6 LABORATORY NAME T I-- COUNTY ~dA PHONE # 0/ SAMPLING FIRM 1A PHONE # 70j- TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT & PAS DATE INSTALLED 39- C 3� L 3 0 0o r uciccl aso !� r� I 39- 3 - P DOD lirt c 39- 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 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, 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: "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.' 4;,V, r 62. APPLICANTS SIGNATURE O-" fitcll TITLE i I l e A4 M,44 e-6- DATE 6fo-?6e,51 ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME 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) oa o (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES [ ] NO [ ]