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SAN JO/,,,.JIN COUNTY PUBLIC HEALTH S,;VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY 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 /> v ` <br /> REMOVAL ❑ TEMPORARY CLOSURE CLOSURE IN PLACE <br /> rte' <br /> FACILITY INFORMATION <br /> EP IT PROJECT CONTACT pPr PHONE#_rAMrTfIo <br /> Y NAME PHONE# <br /> ADDRESS p C) ► <br /> CROSS STREET F '4 l <br /> OWNER OPERATOR p PHONE# <br /> u <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME <br /> `J CC ADDRESS L ► A LIC# CLASS <br /> SURERvy6RKER COMP# <br /> FIR T <br /> 16BORATORY N E S COUNTY PHONE# <br /> PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- o'b D Lill 6D <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAV_VS,-FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGEN 'S-SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> .� CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED1J.SHAtt-NQT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' C¢N-TRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING. '!CERTIFY THAf IN TH E OF THE WORKFOIT/WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAW ALIFORNIA �. <br /> u APPLICANT'S SIGNATU / TITLE O1`'' DATE I <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> u PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> � � 1. <br /> (e ha i` <br /> EH 23 046(REVISED 08113/99) Page 3 <br />