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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGETANK <br /> CLOSURE IT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUT ES <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DAM DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT PE: <br /> RE OVAL 0 TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE 0 PROJECT C AC P <br /> F IL PHONE i <br /> DRI <br /> SS <br /> CROSS STREET <br /> OWNER TAR PHONE <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR PHOI <br /> E <br /> CONTRACTOK Sz CALIC# C <br /> INSURER WORKER <br /> FIREL7I PERMIT <br /> LABORATORY &HONE 10 <br /> " <br /> E� <br /> TAMC I FOR TION <br /> TAW IO 0 T TAW CONTE 40 P TE INSTALLED <br /> 39. <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> F <br /> 9- <br /> 3 - .m <br /> 39- <br /> 39- hw <br /> 39L T P ALL K IN ACC 4MTH JOA N O ORDINANCES,STATE LA FE LA D R <br /> S AND <br /> OF JOA IN CO E R AL HEALTH PAR LICENSED S S RE TIF <br /> FOLLOWING: w1 CERTIFY T IN THE NCE FOR ICH IS PERMIT IS ISS I T EMPLOY E I <br /> H <br /> ER AS TOO BECOME T TO SC SA LA CALIFORNIA.' CONTRACTORS HIRI ORS TING <br /> C 'nHEa TH LTHAT IN THE PERFORMANCE OF THE WORK FOR ICH TMS PERMlffT IS ISSUED, LL <br /> EMPLOY <br /> PERSONS SUBJE TO WORK SATION LAWS OFCALIFORNIA,' <br /> { <br /> APDL S S 1 TITLE DATE 1 <br /> ❑APPROVED ❑APPROVED}NTH CO NDITION(S) ❑ 1 AF D) <br /> (SEE CCNDITIONS RFLOWANOIOR ON ATTACH <br /> PLAN REVIEWER'SNAME— <br /> ANY DAT E <br /> DEVIATIONS F $r APPLICATION MUST BE SUBMITTED TO IHD FOR APPROVAL PBM T <br /> CONDITIONS: <br /> 111123 046 (Revised 10130110 3 <br />