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SAN J.JQUIN COUNTY PUBLIC HEALTH SJRVICES <br /> .NVIRONMENTAL HEALTH DIVI <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY 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 /> CiZ REMOVAL ❑° TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#0 AC 60 PROJECT CONTACT PHONE# <br /> FACILITY NAME t PHONE# <br /> ADDRESS Sr'L03 - {fit �' `7 2 o0 <br /> CROSS STREET #-1.Cal,"?X <br /> OWNER OPERATOR PHONE# Zk7� ¢ -2O E 1; <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME SEMCO IPHONE# 209-524-9653 <br /> CONTRACTOR ADDRESS 1 21 7 South 7th 'Street CA LIC# 449864 CLASS 1 A HAZ <br /> INSURER state Fund Insurance CaTpany WORKER COMPO 007108-98 ASB C <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME GeoAmalytical COUNTY StanislaUSI PHONE# (209) 572-090-1 <br /> SAMPLING FIRM CeoAnalytical PHONE 209 572-0900 <br /> STANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- lZ Idr e.-cfv �l�I• �� u <br /> 39- ,�'_6 C,4,(, ' (Ze_z, . ttvbvcbir <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT <br /> 939-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 E 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 C PENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN E PERF MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECTTO <br /> WORKER'S COMPENSATION LAWS OF LIFORN <br /> gr 6�� <br /> APPLICANTS SIGNATURE TITLE6 �' <br /> r <br /> ❑ APPROVED PPROVED WITH CONDITION{S} ❑' DISAPPROVED <br /> SEE CONDITIONS BELOWAND/OR ON ATTACHMENT) <br /> /J <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THi,S X PLICATION MUST BE SUBMITTED TO EH13 FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> ZI <br /> �. <br /> I <br /> EH 23 046(REVISED 10119198) Page 3 <br />