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SAN -)AQUIN COUNTY PUBLIC HEAL- 'SERVICES <br />ENVIRONMENTAL HEALTH DTVI„ION <br />APPLICATION 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. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />'1 REMOVAL P; �I _I o"kj ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />FACILITY INFORMATION <br />TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />EPA SITE # PROJECT CONTACT E 2 ENS T- <br />PHONE ZS ? CD% <br />FACILITY NAME Wei £2 LO 0 S A E I I <br />I PHONE # C -c9 93 - .?L-7 <br />ADDRESS '431,5- E.. LJ ATE2top 4 - $-f6CC V roe j <br />INSURER <br />CROSS STREET A W q <br />OWNER OPERATOR EQV , V A ER_12 PCIlf T•A <br />PHONE . qLS 7 6& -39 9 3 <br />CONTRACTOR INFORMATION <br />TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />CONTRACTOR NAME LC- rG ca V ti L E.S <br />/ 67.0,00 6-^soI/Z - 9(0 <br />I PHONE tt aq `I y y' 1 7i3O <br />CONTRACTOR ADDRESS .52-7 N .- pRl2 `�%�” E w <br />- F,2E'SNe CA LIC # 70 tcy 9 Z CLASS A - o1A Z <br />INSURER <br />WORKER COMP# <br />FIRE DISTRICT I.JATF/-I-l60 <br />PERMIT# <br />39 - <br />LABORATORY NAME lit N T .�L.� <br />COUNTY U I U <br />1 PHONE S U 217 7-y800 <br />SAMPLING FIRM CPt IrLi A <br />PHONE # 0,0)y2.O <br />-,3 ao <br />TANK INFORMATION <br />TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />39- <br />/ 67.0,00 6-^soI/Z - 9(0 <br />39- <br />a Dao C-1Aso96 <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 AGENT'S 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." 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 SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURrA-4 1..) - llef -� TITLE .S �� �=� -TEc.K DATE 3-21- - O I <br />❑ APPROVED A PPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) �� <br />PLAN REVIEWER'S NAME DATES -10( <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />