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SANI&AQUIN COUNTY PUBLIC ENVIRONMENTAL HEALTH APPLICATIONi •STORAGE THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 9Q DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: Q TEMPORARY CLOSURE 0 CLOSURE IN PLACE • -, •- r .. . ► FACILITY INFORMATION EPA SITE it CAL PROJECT CONTACT PHONE# q2.5'' FACILITY NAME � - �. PHONE # ` O ADDRESS 9:nke 211 CROSS STREET PHONE # nl"0a OPERATOR APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, ,STATE LAWS, f EDERAL, AWS.,.ANO' RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED Ada T'.S $IGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL N T N.R..OY ANY PERSOW 'IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA CONTRACTOR'S HIRING OR SOBCONTRACTING 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 OF CALIFORNIA." p APPLICANTS SIGNATURE TITLE OAPPROVED 0 APPROVED WITH CONDITION(S) (SEEICONDMONS BELOW ANDIOR ON ATTACHMENT) PLAN REVIEWERS NAMF* DATE DEVIATIONS FR,:�V,ryucCA ION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCINg WORK. CONDITIONS: &JIM� • ��lrii� APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, ,STATE LAWS, f EDERAL, AWS.,.ANO' RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED Ada T'.S $IGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL N T N.R..OY ANY PERSOW 'IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA CONTRACTOR'S HIRING OR SOBCONTRACTING 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 OF CALIFORNIA." p APPLICANTS SIGNATURE TITLE OAPPROVED 0 APPROVED WITH CONDITION(S) (SEEICONDMONS BELOW ANDIOR ON ATTACHMENT) PLAN REVIEWERS NAMF* DATE DEVIATIONS FR,:�V,ryucCA ION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCINg WORK. CONDITIONS: