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f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT 1�ti1 I HIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANC ES T STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE DO NOT WRITE IN ANY SHADED AREAS INDICATE PERMIT TYPE AREMOVAL ❑ TEMPORARY CLOSURE CLOSURE IN PLACE FACILITY LITY INFORMATION VX EPA &ITE PROJECT CONTACT PHONE# b a 1_917Y NAME PHONE# ADDRESS CROSS STREET v OWNER OPERATOR PHONE# CONTRACTOR INFORMATION CONTRACTOR NAME L., PHONE# C ADDRESS L ' A LIC# CLASS SURER RKER COMP J FIR T BORATORY N E S COUNTY41 PHONE# �` Z I PHONE k TANK INFORMATION t1� TANK ID# TANK SIZE TANK CONTENTS (PRESENT& PAST) DATE INSTALLED 39- D 6D � 39- E7 39- 39- 39- . 39- APPLICANT 939- 39- 39- APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LANLSr-FEOtiAL LAWS AND RULES AND ! REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES OWNER OR LICENSED I ADEN &1G>9TURE CERTIFIES THE FOLLOWLNG I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED OT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOmE SUBJECT TO WORKERS COMPENSATION LAWS OF CALIFORNIA CST TOR S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES 1 "HE FOLLOWING CERTIGY TH IN TH E OF TH��Oa�ICH THIS PERMIT IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKER S COMPENSATION LAW ALIFORNIA APPLICANTS 51GNATU TITLE DATE O APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED .yI f"rl- - —_ - - _ _ _(SEE CONDITIONS BELOWAND/OR ON ATTACHMENT) PLAN REVIEWERS NAMEA DATET ` ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK CONDITIONS: x� J ii u 7 y i