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DocuSign Envelope ID: 3E840329-DB85-47BE-991 B-A6FA17D075C4 <br />Ium, <br />ENVIR0NM NTAL SERV CESLTH <br />i4PPL CAT0 m� FOR UNDERGROUND STORAGE <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 />LJ REIIIIIOVAL <br />❑ TEMPORAR`>r CLOS�CRE <br />❑CLOSURE <br />IIV PLACE <br />CONTRACTOR NAME <br />e /r OsG InPG_ <br />FACILITY INFORMATION <br />_ i <br />PHONE #Zz ! j 4� 7t <br />CONTRACTOR ADDRESS <br />EPA SITE C E r <br />O PROJECT CONTACTA/Z/{}�/�� <br />CLASSf{ <br />INSURER <br />'' ` '�';`p <br />FACILITY NAME Si/f'E <br />,Z7 ,rtAL EZI% f ! <br />f� <br />FIRE DISTRICT Gr ?"v <br />PHONE # <br />ADDRESS <br />774 <br />LABORATORY NAME <br />CROSS STREET <br />COUNTYf <br />Fi ( <br />PHONE #�0 1'2 3 <br />SAMPLING FIRM <br />OWNER OPERATOR / <br />t2 (.( <br />! t <br />('ZT/ '� <br />PHONE # <br />it <br />- -- -- <br />. — <br />— <br />',' <br />CONTRACTOR <br />INFORMATION <br />TANK CONTENTS (PRESENT AND PAST) DATE INSTALLED <br />- <br />CONTRACTOR NAME <br />e /r OsG InPG_ <br />�_,� -051 5 9-- <br />_ i <br />PHONE #Zz ! j 4� 7t <br />CONTRACTOR ADDRESS <br />�;�'`- <br />r! CA LIC # <br />CLASSf{ <br />INSURER <br />"�%' -0 51 <br />WORKER <br />COMP# <br />f� <br />FIRE DISTRICT Gr ?"v <br />Dr5'l�Gr�To <br />PERMIT # <br />774 <br />LABORATORY NAME <br />S / L V Z <br />COUNTYf <br />Fi ( <br />PHONE #�0 1'2 3 <br />SAMPLING FIRM <br />l <br />PHONE # <br />! t <br />- <br />it <br />- -- -- <br />. — <br />— <br />TANK INFORMATIOP�i <br />TANK ID # <br />TANK SIZE <br />TANK CONTENTS (PRESENT AND PAST) DATE INSTALLED <br />- <br />�_,� -051 5 9-- <br />�;�'`- <br />"�%' -0 51 <br />a1 <br />f� <br />774 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, RND 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />DocuSlgnerdlby: /,�,• <br />�vZ <br />APPLICANT'S SIGNATURE TITLE (% t)A)sl C DATE 6/20/2023 <br />Pedro o£�2ba4E€�d3asll <br />❑ APPROVED APPROVED WITH CONDITlON(S) ❑DISAPPROVED <br />EE ITIONS BELOW ANDlOR ON ATTACt-IMENT} <br />PLAN REVIEWER'S NAM DATE 2% 23 <br />ANY DEVIATIONS FROM THIS APPL TION A9UST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />