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r o , A APPLICATION•R UNDERGROUND STORAGE i PERMIT THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: ❑ REMOVAL ❑ TEMPORARY CLOSURE Wl c1 nS1 IRI= IN DI At -I= TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED _39- .39- .39- 39- .39- L 39- APPLICAN 9- 39- 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: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENS6TION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE 110AL DATE /� I ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 8/1/11) 3 FACILITY INFORMATION EPA SITE #CALO() 004(.p 4' 1 PROJECT CONTACT m PHONE# 3. n z FACILITY NAME (�„ ` PHONE # L 7 ADDRESS (3 cyt, SkvcA-_A%! CROSS STREET 52..5�51. 1C (P 21 f 3 j OWNER OPERATORI PHONE # -� • ��L7 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED _39- .39- .39- 39- .39- L 39- APPLICAN 9- 39- 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: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENS6TION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE 110AL DATE /� I ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 8/1/11) 3 CONTRACTOR INFORMATION CONTRACTOR NAME farP„C, SeoMPS ty)c,, I PHONE # q 25- 6-1 . C) CONTRACTOR ADDRESS 3_53 ��.1C 1� ly �p(k�f �/, .( U'lW-4VyVlrj CA LIC # So j 5 k 1 CLASS A, Ce INSURER 1'LGL+ -CiM lvkS� Co,. WORKER COMP# 52..5�51. 1C (P 21 f 3 j FIRE DISTRICT r lY� PERMIT # i` i2 - 093 f LABORATORY NAME COUNTY PHONE # SAMPLING FIRM ua PHONE # Ly TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED _39- .39- .39- 39- .39- L 39- APPLICAN 9- 39- 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: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENS6TION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE 110AL DATE /� I ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 8/1/11) 3