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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 TH APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: ❑ REMOVAL EMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# PROJECT CONTACT 7 PHONE# Z FACILITY NAME 4G %/c ?-,21a PHONE# ADDRESS CROSS STREET LIDG•r✓ `T��C.� OWNER OPERATOR 04)^�Ldt / 4 /L I PHONE# T Z CONTRACTOR INFORMATION CONTRACTOR NAME -3 7/4 C PHONE# L c� CONTRACTOR ADDRESS CA LIC# l CLASS e--z4 INSURER WORKER COMP# FIRE DISTRICT PERMIT# LABORATORY NAME COUNTY IPHONE# SAMPLING FIRM PHONE# TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED 39- 00 AiliU 0,^) >; -39- 39- -39- . 39- 139- 1 APPLICAN 9- 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 FOLLOWING: THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S 0 ENS 10 ORNIA." p APPLICANT'S SIGNATURE TITLE , /1/(Lr/� DATE !7 10 7 IL ❑ APPROVEDPPROVED WITH CONDITION(S) ❑ DISAPPROVED EE CON ONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE G/ ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 07/31/09) 3