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S O N JOAQUIN O 11 Q I I I N Environmental Health Department — COUNTY— APPLICATION O U N TYU-14 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 THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: %REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION f EPA SITE # PROJECTCONTACT PHONE# FACILITY NAME I yi PHONE # ADDRESS CROSS STREET OWNEROPERATOR LCA 'CZ'R" W PHONE 1 � CONTRACTOR INFORMATION NTRACTOR NAME i y6J PHONE R I CONTRACTOR ADD E S " lam CA LIC # CLASS ✓ 111,11\, INSURER \ \ CRS WORKER COMP# WC,421 O QV Z� 'k\� FIRE DISTRICT t PERMIT ik - ` BORATORY NAME a % \ C COUNT 9f PHONE Z SAMPLING FIRM \ PHONE Z TANK INFORMATION TANK ID # TANK SIZ TANK CONTENTS PRE ENT AND PAST DATEINSTALLBD 39- 052 0 a , vo 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 WORK R'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLL G: "I CER I Y THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT T ORKKEER''SCOMP N ATION LAWS OF CALIFORNIA." . APPLICANT'S SIG URE " "' TITLE • - DATE ❑ APPROVED P EWITHNDITIONS) ❑ DISAPPROVED E f ATTACHMENT) �PLAN REVIEWER'S NAME � DATEANY DEVIATIONS FROM THIS APPLICATION MEHD FOR APPROVAL PRIOR TO COMMENCING WORK: 3of10