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a � SAN JO!,� UIN COUNTY PUBLIC HEALTH ' _ VICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT r; ek9c-L THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARD US SUBSTANCES STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: ;11 -REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE tom/ C/�Cb Q p FACILITY INFORMATION CONTRACTOR NAME CONTRACTOR ADDRESS EPA SITE # PROJECT CONTACT PHONE# FACILITY NAME U. �'� ' `� V'O 1' V, 'E - PHONE # ADDRESS 3 U'. L 1,1 LVL? C Ste' C vtok-' Lia C:\S CROSS STREET S OWNER OPERATOR Gt `� _ PHONE # 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 OF CALIFORNIA." ,, •• ,, APPLICANT'S SIGNATURE Cal TITLE W 1n l� DATE -LZ tt Z Icl ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE /CONDITIONS BELOW ANDIOR ON ATTACHMENTS PLAN REVIEWER'S NAME i s=3�r " '" DATE la -1 L l ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: A xd&:1a YPA F- C �1- ki S C- 3 EH 23 046 (REVISED 10!19%98) Page 3 FA Vu CONTRACTOR INFORMATION CONTRACTOR NAME CONTRACTOR ADDRESS PHONE # •� L- �n Kl> CA LIC # �Z 3 Lf l CLASS A i� W Z INSURER WORKER COMP# FIRE DISTRICT PERMIT # LABORATORY NAME COUNTY PHONE # SAMPLING FIRM PHONE # 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 OF CALIFORNIA." ,, •• ,, APPLICANT'S SIGNATURE Cal TITLE W 1n l� DATE -LZ tt Z Icl ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE /CONDITIONS BELOW ANDIOR ON ATTACHMENTS PLAN REVIEWER'S NAME i s=3�r " '" DATE la -1 L l ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: A xd&:1a YPA F- C �1- ki S C- 3 EH 23 046 (REVISED 10!19%98) Page 3 FA Vu TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTnS (PRESENT & PAST) DATE INSTALLED 39- �f — 01 5,000 &Ct 39- 0 d, Gt `� 39-.68-6 00 ` 39- 1 7A0 4 I ` 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 OF CALIFORNIA." ,, •• ,, APPLICANT'S SIGNATURE Cal TITLE W 1n l� DATE -LZ tt Z Icl ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE /CONDITIONS BELOW ANDIOR ON ATTACHMENTS PLAN REVIEWER'S NAME i s=3�r " '" DATE la -1 L l ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: A xd&:1a YPA F- C �1- ki S C- 3 EH 23 046 (REVISED 10!19%98) Page 3 FA Vu