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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 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 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# PROJECT CONTACT' y y r �• PHONE# &o ^n C FACILITY NAME _ PHONE, - ADDRESS - ' s CROSS STREET OWNER OPERATOR,j 1 �Q PHONE# I d CONTRACTOR INFORMATION CONTRACTOR NAME _ 77y,gm PHONE# I�p ID CONTRACTOR ADDRESS, r ( Ca(- } CA LIC# CLF SS OAZ- INSURER ,a' r ) WORKER COMP# , FIRE DISTRICT PERMIT# r LABORATORY NAME Sq�,a VXv I COUNTY PHONE# SAMPLING FIRM ca _ - ) o a PHONE# TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST) DATE INSTALLED 39-7 0/8/fOO );tpop ' 39- ,7/5180`7" - a 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 {2 ER'S COMPENSATION LAWS OF CALIFORNIA." ` APPLICANT'S SIGNATURE s Q , TITLE C-f3l- L� 8SA-,y �,rne- DATE ` ❑ APPROVED ❑.APPROVED WITH CONDITION(S) ❑ DISAPPROVED —(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE� G//V ANY DEVIATIONS FROM THIS APPLIMUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 10/30/12) 3