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1 SAN JOAQUIN COUNTY ENWONMENTAL HEALTH DEPARTOT - APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMAES 90 DAYS FROM CLOSURE OR DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPEBANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS S STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE 77-77 :;FACILITY INFORMATION . IROJECT CONTACT CG PHONE# 0 C'E EPA SITE# PHONE# LU FACILITY NAME S/ C � C ADDRESS .� CROSS STREET PHONE# OWNER OPERATOR l - CONTRACTOR INFORMATION _-- =- PHONE# 2E' n Z ..� �`/ CONTRACTOR NAME /� e` CA LIC# �� CLASS CONTRACTOR ADDRESS �i INSURER �/ /7. /. WORKER COMP# � T, I /� —� FIRE DISTRICT 'Tr PERMIT# COUNTY �i?.�.J PHONE# LG � �7 ?- LAB( LABORATORY NAME O PHONE # ' SAMPLING FIRM i TANK INFORMATION = TANK SIZE TANK C DNTENTS PRESENT& PAST) DATE INSTALLED TANK ID ------ 39- 39- 39- 3 9- 39- 39- 39- APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,ANO RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 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 SUBJECT TO WORFOLKER'S COMP 1 C, IIT AON LAW FTHE PER S CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSON _ APPLICANTS SIGNATURE ITLE ❑APPROVED.: APPROVED'WITH CONDITIONS) .4- ❑ DISAPPROVED :.(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) DATE PLAN REVIEWER'S NAME " = ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WOR CONDITIONS: c_ �Fcr etc C�CN.�,��c. Page 3 EH 23 046(REVISED 3/15/02)