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• 0 ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENT/'TEMPORARY 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 FACILITY INFORMATION EPA SITE ��;7--SPROJECT CONTACT (L, 1 PHONE# ff - (- FACILITY NAME PHONE # ADDRESS CROSS STREET OWNER OPERATOR I PHONE # TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED 39- p 51 t�f 2- 3o Q i*0 c, 39- 051 565 If 000 39- 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 FO VVLNQ.. I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC 0 WORKER'S COMPENSATION LAWS OF CALIFORNIA." C, w (� .._...�J �L IL. APPLICANT'S SIGNATURE , TITLE �,LtJ�V1 Z DATE UZ �� /- 12 ❑ APPROVEDAPPROVED WITH CONDITION(S) ❑ DISAPPROVED (E CO 6 S BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAM—DATE c *e -- ANY DEVIATIONS FROM THISPLI TION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. 7 CONDITIONS: EH 23 046 (Revised 07/22/10) A•Z MuJre— CONTRACTOR INFORMATION CONTRACTOR NAME ' �. I PHONE # - CONTRACTOR ADDRESS CA LIC # 7 CLASS INSURER WORKER COMP# FIRE DISTRICT / y ! } } L PERMIT # �e �� ( irfLf LABORATORY NAME eC COUNTY PHONE # SAMPLING FIRM A • C I' PHONE # Vrq.41l TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED 39- p 51 t�f 2- 3o Q i*0 c, 39- 051 565 If 000 39- 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 FO VVLNQ.. I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC 0 WORKER'S COMPENSATION LAWS OF CALIFORNIA." C, w (� .._...�J �L IL. APPLICANT'S SIGNATURE , TITLE �,LtJ�V1 Z DATE UZ �� /- 12 ❑ APPROVEDAPPROVED WITH CONDITION(S) ❑ DISAPPROVED (E CO 6 S BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAM—DATE c *e -- ANY DEVIATIONS FROM THISPLI TION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. 7 CONDITIONS: EH 23 046 (Revised 07/22/10) A•Z MuJre—