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SAN JO*,JIN COUNTY PUBLIC HEALTH SO✓ICES �t�- 60P7 ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTITEMPORARY 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: C REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# "j Z, PROJECT CONTACT v PHONE# FACILITY NAME PHONE# 3 ADDRESS C-. CROSS STREET t OWNER OPERATOR WC2616,214PHONE# ]_. CONTRACTOR INFORMATION CONTRACTOR NAME i t PHONE# CONTRACTOR ADDRESSMT CA LIC# CLASS INSURER s WORKER COMP# FIRE DISTRICT s PERMIT# LABORATORY NAME I..w. COUNTY PHONE# SAMPLING FIRM PHONE it TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED 39- c' In 39- — 1 Q i39- 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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: *1 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 CALIFORNIA.' APPLICANTS SIGNATURE TITLE DATE 12-- 0 ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE 2 Agf- ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHE FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: of h D 1:4 i- c,. EH 23 046(REVISED 10119 8) -- 30 lb5e- GLU el-c((C'>',s QS