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1:11V11'Oiimental I lealth Department <br /> 1:1 C 0 lIJ fr"l,It-�Y '�J ��) �-�, � 1 r Ir <br /> ���,� 0VE D <br /> PPUC ;MN FOR U1NDrER GG OUND STORA OE TANP "- 19 2020 <br /> CLOSURE o TERN l( ENVIRONMENTAL_ HEALTH <br /> PERM IDSEI-WICES <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS <br /> SUBSTANCES STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. <br /> INDICATE PERMIT TYPE: <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#6 411- PROJECT CONTACT Lr �/� (� y PHONE## 0c. 3 Z 1 <br /> Wl <br /> FACILITY NAME PHONE#2,r9 9 �7�5 �✓�� <br /> ADDRESS 62 N()r 9 15�zU <br /> CROSS STREET �d Z ter_ `7& r// <br /> OWNER OPERATOR ��r/" Cf g PHONE#,.-9 `-0 11 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME a)// !2 P6 0//— ./I0 C' PHONE#Z9 c CZE,S` <br /> CONTRACTOR ADDRESS �( C- CA LIC# ! %% CLASS / Z <br /> INSURER /,' t 6/ 7S . tr/_ 6,9� WORKER COMP# <br /> FIREDISTRICT,i/ T ,CI —S5Ie)e-Xl&7,0 PERMIT# <br /> LABORATORY NAME COUNTY _ , PHO--NE-#%V <br /> SAMPLING FIR ) I G' !) `� rtir7� A PHONE# �I� , !rt^0;�} `.7 Ad <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39- � 1� U,aIC� -!)�J /� gr�Ii '�'1 ��.� (V/,v <br /> 39- 3 <br /> 39- `-f 5 <br /> e5C/ S017 71,,e 1-dr ":/-2- <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 FO <br /> ICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION WS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PE RMANGE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER' C•MPENSATION LAWS OF C LIFORNIA.' <br /> /�{IILE ���1 1 �/G 7e t� DATE <br /> APPLICANT'S SIGNATURE i �l� /' <br /> ❑ APPROVED APPROVE ITH CONDITION(S) ❑ DISAPPROVED <br /> I (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME �OU^ \ DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EIiD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> 3of10 <br />