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SAN •JIAQUIN Environ Rle�'I�, Dea COUNTY---- (?('( APPLICATION FOR UNDERGROUND STORAG �EN7- CLOSURE PERMIT THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 980 DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: iR REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE CONTRACTOR INFORMATION CONTRACTOR NAME I. & I PHONE # 551-44q-1-2.90 CONTRACTOR ADDRESS 38$7 /J Vq l -e-, I4� I CA LIC #-77 q'Z(o? I CLASS A $ L INSURER oqL+^i trt/ �+�5 V / 9 .z�� WORKERCOMP# �L' L 1 eh svZ FIRE DISTRICT S'ic�cAdScA PERMIT# LABORATORY NAME "` ` COUNTY PHONE # O SAMPLING FIRM ItPHONE# FACILITY INFORMATION TANK ID # TANK SIZE EPA SITE # PROJECT CONTACT PHONE# FACILITY NAME Z*OIJ3Z IPHONE# ADDRESS LitoZl i vv"r u R I-zo CROSS STREET OWNER OPERATOR -%' t _ S L, -,,j ,go ,A PHONE # -7tL'I --)`71-5 {Sf CONTRACTOR INFORMATION CONTRACTOR NAME I. & I PHONE # 551-44q-1-2.90 CONTRACTOR ADDRESS 38$7 /J Vq l -e-, I4� I CA LIC #-77 q'Z(o? I CLASS A $ L INSURER oqL+^i trt/ �+�5 V / 9 .z�� WORKERCOMP# �L' L 1 eh svZ FIRE DISTRICT S'ic�cAdScA PERMIT# LABORATORY NAME "` ` COUNTY PHONE # O SAMPLING FIRM ItPHONE# 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 TION LAWS OF CALIFORNIA.' APPLICANT'S SIGNATURE TITLE Z6DATE ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EMD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: 3 of 10 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRE ENT ND PAST) DATE INSTALLED 39- / /D D 7 C�/7 39- Z 39- PIL0n?&�- 39- 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 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 TION LAWS OF CALIFORNIA.' APPLICANT'S SIGNATURE TITLE Z6DATE ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EMD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: 3 of 10