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SAN JUAQUIN COUNTY PUBLIC HEALTI SERVICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK 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. POIAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE # G& PROJECT CONTACT I ' VcFG PHONE# 7ZII I --cr'333 FACILITY NAME ��} _ Z V E S f PHONE v ;- et _� ADDRESS / U r CROaS.STREET I&OW= �TlJ %C? WN PERATOR p� °-4>= — I PHONE #,I r , CONTRACTOR INFORMATION CONTRACTOR NAMES .V PHONE #^ CONTRACTO : ADDRESS .'U C CA LIC # INSURER WORKER COMP# Z FIRE DISTRICT G PERMIT # _ LABORATORY NAME COUNTY PHON SAMPLING FIRM AA: rU n 'ti � PHONE # I LIC" TANK INFORMATION TANK ID # A K SIZE TANK CONTENTS PRESENT & PAST DATE INSTALLED 39- 6GISa 7 1 vL�t :��jE- � � �r •� 39 39- 39- 39- 39- APPLICANT 9-39- 39-39- APPLICANT MUST PERFORM ALL WORK RJ AC RDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS , AND RULES AND REGULATIONS OF SAN JOAQUIN CO TY P ELIC HEALTH SERVICES . OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING'. "I CERTIFY THAT IN THE PERFORMANC F T E WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER' CDM WOR LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING' 11 ANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO W ORKER'S COMPENSA APPLICANTS SIGNATURE __ TITLE - "P /y2 DATES Z'-Z- ❑ APPROVED AAPPROVED WITH CONDITION(S ) ❑ DISAPPROVED L (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) J PLAN REVIEWER'S NAME x k' N iii DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. _ � CONDITIONS : s 7' EH 23 046 (REVISED 08/13199) Page 3