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SAN JUIN COUNTY PUBLIC HEALTH VICES VIRONMENTAL HEALTH DIVISI APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTITEMPORARY 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 PEMIT TYPE: ® REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE.iN PLACE d FACILITY INFORMATION EPA SITE # CAL 0CJWT40 PROJECT CONTACT PHONE# FACILITY NAME CN—jt—j Ii q- 3).32. PHONE ADDRESS CROSS STREET Q @WM61� OPERATOR P NE # rl'-01 I APPLICANT MUST PERFORM ALL WORK IN ACCORDA CE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC TH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE K FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSfMON LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PER RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFO NIA." 1 APPLICANT'S SIGNATURE TITLE (i.\ Ak/A— DATE 12el) 3 ❑ APPROVED CONTRACTOR INFORMATION CONTRACTOR NAME\,Jf INc PHONE # b syr- 8310 CONTRACTOR ADDRESS Q LIC # 0 CLASS N INSURER TnS. WORKER COM I I FIRE DISTRICT PERMIT # LABORATORY NAMES sl k0S � COUNTY PHONE # 600 SAMPLING FIRM PHONE702 -,!Q APPLICANT MUST PERFORM ALL WORK IN ACCORDA CE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC TH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE K FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSfMON LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PER RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFO NIA." 1 APPLICANT'S SIGNATURE TITLE (i.\ Ak/A— DATE 12el) 3 ❑ APPROVED PROVED WITH CONDITION(S) ❑ DISAPPROVED TANK INFOR ATION (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) TANK ID # TANK SIZE A TANK CONT TS (PRESENT & PAST) DATE INSTALLED 39- / -- c),v I oop Cr&\"'w- o: i F 39- _ o ln ©w 2 39- j Z 4 co 39- — d dU 39- 39 - APPLICANT MUST PERFORM ALL WORK IN ACCORDA CE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC TH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE K FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSfMON LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PER RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFO NIA." 1 APPLICANT'S SIGNATURE TITLE (i.\ Ak/A— DATE 12el) 3 ❑ APPROVED PROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S N E G DATE j � 7 ANY DEVIATIONS FROM THIS A CATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: fPCa� k b EH 23 046 (REVISED 10/19/98) Page 5