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0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENT) TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />K REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />EPA SITE # PROJECT CONTACT . PHONE# <br />FACILITY NAME 0�� r //e I f'V ry,�, ✓11►)(t����� I , _ PHONE # <br />ADDRESS f �, ! ! �(/ `✓, <br />CROSS STREET IP �� <br />OWNER OPERATOR f�, �C' ='T�,� J��,I PHONE # <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br />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 <br />MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." � (� // <br />APPLICANT'S SIGNATURE / TITLE �I(—C `j � GT / ' DATE 7 6 <br />❑ APPROVED M APPROVED WITH CONDITION(S) LJ DISAPPROVED <br />(SEE CONDITIONS BELOW AND/OR QN ATTACHMENT) <br />PLAN REVIEWER'S NAME e DATE <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />EH 23 046 (Revised 10/16/03) Page 3 <br />