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SANQUIN COUNTY PUBLIC HEALT ERVICES ENVIRONMENTAL HEALTH DIVIWN APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TA (S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE CONTRACTOR FACILITY INFORMATION EPA SITE # PROJECT CONTACT -rl� PHONE# 7110 �� FACILITY NAME7 / PHONE # OQ ,s ADDRESS A-). AWMMA OLT A8 CROSS STREET kC U -j) :jj Ab OWNER OPERATOR j o - (j / OCAPA17V PHONE # (71067o-, TANK INFORMATION CONTRACTOR INFORMATION CONTRACTOR NAME U OA PHONE # %- 93/0 CONTRACTOR ADDRESS / CA LIC # CLASS INSURER WORKER COMP# FIRE DISTRICT PERMIT # LABORATORY NAMEt %JFJk/ C'fl� COUNTY PHONE # SAMPLING FIRM PHONE # TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- b f / 39- 39- 39- 39- 39 - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. 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 CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS F CALIFO 1 ." APPLICANT'S SIGNATURE TITLE DATE DATE ❑ APPROVED U,4PPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE �DITIONS LOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. Page 3