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SAN JOAQUIN COUNTY f E iRONMENTAL HEALTH DEPARTP, 4T APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FQR 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 XREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION ' EPA SITE# PROJECT CONTACT M urIC ?L1L U PHONE# F/-( 9'1 Lf—21 i'4( FACILITY NAME 0,1t fSt PHONE#_269 y/ -?30 ADDRESS Q0 CROSS STREET o42 IcA OWNER OPERATOR Q r' 6er4Lbd i coA PHONE# (2o4) ' CONTRACTOR INFORMATION CONTRACTOR NAME n✓ r rrr� n cen 4- e� Af Ghc, PHONE# ! —66 ~Z 3 00 CONTRACTOR ADDRESS 5'01 PArKC ,- t- -c c,H tb aYra G CA LIC# MM-Ll'lY 3.26} CLASS /f N*7- ' INSURER G & WORKER COMP# �UGC7 c�1 FIRE DISTRICT o�ty�Zart PERMIT# LABORATORY NAME Ca l j r a rClKe COUNTY PHONE# l/6 —,4 38- —7-301 ' SAMPLING FIRM o ba rn,r� PHONE= p TANK INFORMATION ' TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED 39- 139- 39- 39- 39- APPLICANT 9-39- 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 AGENTS 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 WORKERS COMPENSATION LAWS OF CALIFORNIA' CONTRACTORS 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' APPLICANT S SIGNATURE TITLE �!�� r{� cls DATE I Z D ❑ APPROVED APPROVED WITH CONDITION(SQ � ) ❑ DISAPPROVED (SE ONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAMEAkr� ,, DATE 1 ANY DEVIATIONS FROM THIS APPLICATION MUST E SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING ORK nn DITIONS 40 EH 23 046(REVISED 3115/02) Page 3