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ENVIRO1NMI TAL HEALTti DEP-A TM ENT SAN JOAQUIN IN COUNTY APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTITEMPORARY 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 T YPE 1I!J REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE C AC odZ 64 6 FACILITY INFORMATION EPA SITE#E.' �� i�Y ROJECT CONTACT C c_G' �t7 tr ✓ PHONE#` % S F 7 u' c PflONE FACILITY NAME ADDRESS n CROSS STREET OWNER OPERATOR �_% £>'� PHONE CONTRACTOR INFORMATION CONTRACTOR NAME - a r < _ t tr ^-: i' PHONE CONTRACTOR ADDRESS . A LIC# > CLASS,• eC�/� 4 - INSURER F v /-,.It s c G+ WORKER COMP# FIRE DISTRICT j t r[` PERMIT# t9 0 CJ( U r LABORATORY NAME F�/ [�l� a f COUNTY PHONE# -3`� �, I 1 7 ' SAMPLING FIRM PHONE,# *-L: TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED 39- 39- f` 39- 39- 39- 39- APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUjITY 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 FCLLOW�IG. 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT iS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WOR>ER's COiv1PENSATION LAWS OF CALIFORNIA.- - { � APPLICANT'S SIGNATURE' _ iJ = 1 TITLE —DATE � �� ❑ APPROVED Q APPROVED WITH CONDITION(S) Cl DISAPPROVED (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) PLAN REVIEWER'S NAME ill - A)I'P 0-� DATE 161Z,3101 ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHO FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: F.H 23 046 (Revise(107/31/09) 3