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Y <br />6 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />❑ REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />"FACILITY INFORMATION <br />EPA SITE # PROJECT CONTACT f ' 1 I PHONE# <br />FACILITY NAME 11'D46KIGA _ 1 -61 InY'C I IPHONE# -,tUa; - +1/4 - <br />OWNER OPERATOR Heq ruets. JPHONE# <br />;: CONTRACTOR`: INFORMATION <br />CONTRACTOR NAME I V 0ev PHONE # 41�JL <br />CONTRACTOR ADDRESS r, *Y1 I CA LIC # CLASS <br />INSURER WORKER COMP# 'uZC 9 <br />FIRE DISTRICT ' �L f 5 �1 <br />LABORATORY NAME COUNTY I A ONE # <br />SAMPLING FIRM'Ao11(!hP{rl (S.,rn nihir,m"pil PHONE# 269 <br /># I TANK SIZE I TANK CONTENTS (PRESENT AND <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH <br />A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br />SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />EMPLOY PERSONS SUBJECT TO W KER'S COMPENSATION WS OF CALIFORNIA." �J p � <br />APPLICANT'S SIGNATURE �161 t�.'IiTITLE `C &L. DATE <br />❑ APPROVED <br />P,�'ROVED WITH CONDITION(S) " ❑DISAPPROVED ,s <br />;. CONDITIONSBE OW AND/OR ON ATTACHMENT) <br />;PLANREVIEWEf £ E <br />l� y+� DATE <br />ANY�DEYd1A710N5 F OM�gAPPLI,C <br />IOK MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK <br />CONDITI7NS•µ� , <br />EH 23 046 (Revised 07/22/10) 3 <br />k <br />Zat2 <br />