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ENVIRONMENTAL HEALTH DEPARTM T APPLICATION UNDERGROUNDT STORAGE OSURE PERMIT THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: 4"X'REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE T CONTACT PHONE# 91e,. FACILITY NAME Dtt.v7'2 `I'Lc4gp I PHONE # .Z69- 9 p. ADDRESS.zSr"ti' SCeu v:7tY CG'4-o7 CROSS STREET 4VHau7-4w &A=, OWNER OPERATOR •s.t,,wlr,-,v IDLJAAIGi. .. r. .s�v .,1 -yas ,. - 7.i :a v7--r- APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY 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 FOLLOWING: "I CERTIFY THAT IN THE PERFORMAf�CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CAkiFORCNIA." j APPLICANTS SIGNATURE ITLE / 67-�e-C7"" DATE t9 % D TOM t�1S4'r�2 ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVE (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME ?ATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL fP!RIC 1 ME. —ING WORK. CONDITIONS: FH qq ndF /RFS/ICCI�In/1�/n�� 'CUO a 1. (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES [ I NOW 41A-� E CONTRACTOR INFORMATION CONTRACTOR NAME 624,7' A/ PHONE # CONTRACTOR ADDRESS O qA,.v Yei/��AC CA QS" .3 CA LIC # ad ¢ S CLASS,(C6 /.D INSURER 7t :Zr v� Yi H Let t ��ao WORKER COMP# S—a Z - 02 d FIRE DISTRICT 70(�7O� y �e S ,/��op : PERMIT # AVOW. T A0, Ja 1 LABORATORY NAME SAMPLING FIRM TL .Q14 'A -� 411AAn1A-CeWra►, COUNTY .4-41oa.a4 PHONE # 9Z S, 4- p¢, / 919 PHONP 4 �n = CZE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY 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 FOLLOWING: "I CERTIFY THAT IN THE PERFORMAf�CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CAkiFORCNIA." j APPLICANTS SIGNATURE ITLE / 67-�e-C7"" DATE t9 % D TOM t�1S4'r�2 ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVE (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME ?ATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL fP!RIC 1 ME. —ING WORK. CONDITIONS: FH qq ndF /RFS/ICCI�In/1�/n�� 'CUO a 1. (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES [ I NOW 41A-� E TANK INFORMATION TANK ID #TANK SIZE TANK CONTENTS PRESENT & PAS DATE INSTALLED 39- .T4 j,01- - / S' 39- 36/ —Rx 39- 6 r f- L;JG► So 1�irr-E-oiL / 4 P 39- 39- 39- - a r-xsyza APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY 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 FOLLOWING: "I CERTIFY THAT IN THE PERFORMAf�CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CAkiFORCNIA." j APPLICANTS SIGNATURE ITLE / 67-�e-C7"" DATE t9 % D TOM t�1S4'r�2 ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVE (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME ?ATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL fP!RIC 1 ME. —ING WORK. CONDITIONS: FH qq ndF /RFS/ICCI�In/1�/n�� 'CUO a 1. (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES [ I NOW 41A-� E