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E D E kv*;� .nt SAN.,,-JOAQUINRA�IOAQUIN _ ---COUNTY-- OCT 10 2018 mzffllffol IM11 IIEW APPLICATION FOR UNDERGROUND STORW&WTAdNI(T CLOSURE PERMIT THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: ($REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE CONTRACTOR INFORMATION CONTRACTOR NAME t-& I PHONE # 551-444-1-1.90 CONTRACTOR ADDRESS 31 t--) \htL-e^k4 4._ I CA LIC #'72T2407 1 CLASSA $C t Hu INSURER ACO 14Mf-f c l9-,/ '�+�� ,, �_ WORKER COMP# FIRE DISTRICT S96c W�tJ PERMIT # SfbV LABORATORY NAMEI COUNTY PHONE # •1 ` a SAMPLING FIRM j PHONE # `Il- - FACILITY INFORMATION TANK ID # TANK SIZE EPA SITE # PROJECT CONTACT PHONE# FACILITY NAME -A vo&3Z 1PHONE # ADDRESS �oZyi v c i jjhe ug�ZC3 CROSS STREET OWNER OPERATOR 7 -CF -leve., S L---4 ,ga ,D PHONE # -7 k4--77 L-549= CONTRACTOR INFORMATION CONTRACTOR NAME t-& I PHONE # 551-444-1-1.90 CONTRACTOR ADDRESS 31 t--) \htL-e^k4 4._ I CA LIC #'72T2407 1 CLASSA $C t Hu INSURER ACO 14Mf-f c l9-,/ '�+�� ,, �_ WORKER COMP# FIRE DISTRICT S96c W�tJ PERMIT # SfbV LABORATORY NAMEI COUNTY PHONE # •1 ` a SAMPLING FIRM j PHONE # `Il- - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL EMPLOY PERSONS SUBJECT TO WORK 'S PEf1 TION LAWS OF CALIFORNIA.' APPLICANT'S SIGNATURE TITLE Gam/ ' `� .r DATE l ' X,/- 0APPROVEDNrAPPROVED WITH CONDITION(S) ❑ DISAPPROVED /(EE CO ITI S BELOW AND/OR ON ATTACHMENT) j� PLAN REVIEWER'S NAM DATEACL�7 ANY DEVIATIONS FROM THIS ALIC ION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. 3 o110 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRE ENT ND PAST DTE INSTALLED 39- /© D 7 vn 39- 7q? r _101,000 39- 97 -a< 39- 39- 139 - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL EMPLOY PERSONS SUBJECT TO WORK 'S PEf1 TION LAWS OF CALIFORNIA.' APPLICANT'S SIGNATURE TITLE Gam/ ' `� .r DATE l ' X,/- 0APPROVEDNrAPPROVED WITH CONDITION(S) ❑ DISAPPROVED /(EE CO ITI S BELOW AND/OR ON ATTACHMENT) j� PLAN REVIEWER'S NAM DATEACL�7 ANY DEVIATIONS FROM THIS ALIC ION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. 3 o110