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E El ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE APPLICANT'S SIGNATURE: EH 23 046 (Revised 7/10/92) Page 3 TITLE DATE EPA SITE # PROJECT CONTACT A TELEPHONE # F FACILITY NAMEPNONE =AI # A C ADDRESS I L CROSS STREET I T OWNER/OPERATOR PHONE # Y C CONTRACTOR NAME "PHONE # 0 N CONTRACTOR ADDRESS CA LIC # CLASS T R INSURER WORK.COMP.# A C FIRE DISTRICT PERMIT # T 0 LABORATORY NAME PHONE # R SAMPLING FIRM PHONE # 111111111111111111111111111111 TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- 3 39- A 39- N 39- K 39- 39- 39- P 1111IITTIITTTITTIrlITTTTTmillilililI 111111111111111111111 L APPROVED APPROVED WITHCONDITION(S) _....- DISAPPROVED A (SEE ATTACHMENT WITHCONDITIONS) N PLAN REVIEWERS NAME tlllllllltlillllllll DATE Illli APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. 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 SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TOWORKER'S COMPENSATION LAWS OF CALIFORNIA." TRACTOR'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 WORKERIS COMPENSATION LAWS OF CALIFORNIA.* APPLICANT'S SIGNATURE: EH 23 046 (Revised 7/10/92) Page 3 TITLE DATE