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SAP )AQUIN COUNTY PUBLIC HEAL- SERVICES <br /> ENVIRONMENTAL HEALTH DIVIJION <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 /> ❑ REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# \\\ PROJECT CONTACT P ONE# <br /> FACILITY NAME - PHONE# <br /> ADDRESS <br /> CROSS STREET <br /> OWNER OPERATOR Z S PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAMEIOA) PHONE# <br /> CONTRACTOR ADDRESS - OIv CA LIC# 7 CLASS A <br /> INSURER Okm WORKER COMP# <br /> FIRE DISTRICT F / PERMIT# <br /> LABORATORY NAME �(�- 019 COUNTY PHONE# 50. 3�y 9000 <br /> SAMPLING FIRM PHONE <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- <br /> 39- <br /> 39- <br /> 9-39-39- 3 <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> 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 <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING. 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANTS SIGNATURE' 0 OFw��(�� TITLE�C,(J� � 19��7`z-Q DA <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> 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 /> (r) �sl-r& <br /> �2�- CA LL_ L)_sA D I fZ -RD iaxC}AV/i Y 1 o tom) <br /> �{� I Wt 1►--3 /t _ (x I'll - <br /> EH 23 046(REVISED 10 9/98) Page 3 <br />