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SAN JOAON COUNTY PUBLIC HEALTH SEIOCES ENVIRONMENTAL HEALTH DIVISION 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 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- - 5- 39- 39- 39- 39- S .� 39 39- 39-5 C> r, APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA."" APPLICANTS SIGNATUR� ryy " C _ _ TITLE l�(-)J e L �41 I;k DATE 2 ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED ^^�� Q (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME ATC%i�11V r �� Os)"W\' DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: 1. CALL iSlitS tIJ A `bmKicff- Fog, fkt-L T'NS .T70QS AiLL l NIG tAQST ?Z"lQJ 4N TLAC.ZING S 1071L 'PH3:N5Te c.TDW-, ftAS G'k ti'i EH 23 046 (REVISED 10/19/98) Page 3 FACILITY INFORMATION EPA SITE # ' 2 Z PROJECT CONTACT' PHONE !� - FACILITY NAME - W CA LIC # PHONE # ADDRESS -7' zi�:7 SOS 10 CROSS STREET PERMIT # - OWNER OPERATOR N, COUNTY PHONE # l,,) J -A TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- - 5- 39- 39- 39- 39- S .� 39 39- 39-5 C> r, APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA."" APPLICANTS SIGNATUR� ryy " C _ _ TITLE l�(-)J e L �41 I;k DATE 2 ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED ^^�� Q (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME ATC%i�11V r �� Os)"W\' DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: 1. CALL iSlitS tIJ A `bmKicff- Fog, fkt-L T'NS .T70QS AiLL l NIG tAQST ?Z"lQJ 4N TLAC.ZING S 1071L 'PH3:N5Te c.TDW-, ftAS G'k ti'i EH 23 046 (REVISED 10/19/98) Page 3 CONTRACTOR INFORMATION CONTRACTOR NAME S PHONE CONTRACTOR ADDRESS - W CA LIC # V L CLASS Z INSURER FjtEM�r G6 At WORKER COMP# SOS 10 FIRE DISTRICT PERMIT # - LABORATORY NAME N, COUNTY PHONE p SAMPLING FIRM J - PHONE #('_ - TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- - 5- 39- 39- 39- 39- S .� 39 39- 39-5 C> r, APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA."" APPLICANTS SIGNATUR� ryy " C _ _ TITLE l�(-)J e L �41 I;k DATE 2 ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED ^^�� Q (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME ATC%i�11V r �� Os)"W\' DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: 1. CALL iSlitS tIJ A `bmKicff- Fog, fkt-L T'NS .T70QS AiLL l NIG tAQST ?Z"lQJ 4N TLAC.ZING S 1071L 'PH3:N5Te c.TDW-, ftAS G'k ti'i EH 23 046 (REVISED 10/19/98) Page 3