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SAN QUIN COUNTY PUBLIC HEALTH aRVICES NVIRONMENTAL HEALTH DIVISI APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT TIS STIT FOR PERMANENTITEMPORARY CLOSURE OR ANK(S) EXPIRES R ES 90 DAYS FROM THE APPROVAL DATE. DO NOT NMENT WPLACE HAZARDOUS WRITE ANY SHADED AREAS ORAGES TINDICATE PERMIT TYPE. ,REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE APPLICANT MUST REGULATIONS OFSANPERFORM ACCORDANCE A OAOU NCOUNTY PUBUCE HEALTH RVICES.OWNER OR OUIN LIAND LICENSED GENTS SIGNATURE CERTIFIES THE FOLLOWING:FOLLOWING: CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO THE O� OWING JME E T TO WORKER'S COMPENSA' ION LAWS OF CALIFORNIA.* CONTRAcOR'S HIRING OR CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SUBCONTRACTING HALLEMPLOY PERSONS SUBJECTTO WORKER'S COMPENSATION LAWS OF CA IFORNA.- APPLICANTS SIGNATURE t TITLE V�1� -� =- OA i E ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPUCATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: Page 3 FACILITY INFORMATION EPA SITE # DO eq��, e,.� PHONE# Z�f q�9 PROJECT CONTACT ,, ,.. °> L' FACILITY NAME !j PHONE ADDRESS �7T CROSS STREET NGoL OWNER OPERATOR j Cyr G(AY P,IZlrrJE� IES PHONE # CONTRACTOR INFORMATION CONTRACTOR NAME I/A/1/C� — N - PHONE # Z L ST CA LIC # �GBD X27 CIASS CONTRACTOR ADDRESS G /1/ G✓A INSURER tJ 6r / S WORKER COMP# FIRE DISTRICT lj-/�G� f� I PERMIT* LABORATORY NAME (� COUNTY PHONE # SAMPLING FIRM �jIJ /�J� PHONE a D7 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INST, 39- ®era a l� 39- 39- d DIGS 39- 39- 39- APPLICANT MUST REGULATIONS OFSANPERFORM ACCORDANCE A OAOU NCOUNTY PUBUCE HEALTH RVICES.OWNER OR OUIN LIAND LICENSED GENTS SIGNATURE CERTIFIES THE FOLLOWING:FOLLOWING: CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO THE O� OWING JME E T TO WORKER'S COMPENSA' ION LAWS OF CALIFORNIA.* CONTRAcOR'S HIRING OR CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SUBCONTRACTING HALLEMPLOY PERSONS SUBJECTTO WORKER'S COMPENSATION LAWS OF CA IFORNA.- APPLICANTS SIGNATURE t TITLE V�1� -� =- OA i E ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPUCATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: Page 3