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ENVIRONMENTAL HEALTH DEPARTME T SAN JOAQUIN COUNTY APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SU STANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PE MIT TYPE: )REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN P E TANK INFORMATION FACILITY INFORMATION EPA SITE #GA//) y913677 �/l PROJECT CONTACT 41 � V I PHO NE# 2 d FACILITYNAME /Z£G GS S(%G / 49-VSf-,IPHONE# ADDRESS 0LO o LL ' /(./,E= CROSS STREET 6 OWNER OPERATOR /L F £ L SGI Ei RiM /'A.IV PHONE # % TANK INFORMATION CONTRACTOR INFORMATION CONTRACTOR NAME PHONE # 2-c47" 32 �%FI CONTRACTOR ADDRESS Io2 0 6 0 e�5_2_cfA CALIC# CLASS tij J1,fZ INSURER //% %N 4.t/l 34z WORKER COMP#3TC,-Z, ;,) %X 7//7j—/U FIREDISTRICT LABORATORY NAME SAMPLING FIRM iv% PERMIT# _x ii 4 .c G COUNTY f 1V �y/,f PHONE # � �% 9Z a. i PHONE # 20 3 S_ TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTA LED 39- 5/ £ �✓ �Oc 39- 39- 39- 39- 39 - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AN RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CE TIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PER ON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA! CONTRACTOR'S HIRING OR SUBC NTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSU�D, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS.OFi. UFORNIA.' APPLICANT'S SIGNATURE IZAPPROVED 19APPROVED WITH CONDITION(S) ❑ DISAPPRDVED EE CONDITIONS BELOW AND/OR ON ATTACHMENT) �J PLAN REVIEWER'S NAME DATE°I� ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. EH 23 046 (Revised 07/31/08)