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SAN JOAQUIN COUNTY IVIRONMENTAL HEALTH DEPARTMENT APPLICATION MR UNDERGROUND STORAGE Tr..4K CLOSURE PERMIT THIS PERMIT PERMANENT)TEMPORARY CLOSURE OR E OF UNDERGROUND HRDOUS NCES STORAGE TANK(S)FOR ABANDONMENT (S)EXPIRES 90 DAYS FFROM HEA PROVAL DATE. DO NOT WRITE CN ANY SHADED AREAS. IINNDIICATE PERMITATYPE: -YkREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# _ S S PROJECT CONTACT TN� 1C PHONE# FACILITY NAME T O PHONE# ADDRESS G,9 %rD� �� CROSS STREET PHONE# d ' OWNEROPERATOR ' / �- o' US # S iU LD v _ CONTRACTOR INFORMATION CONTRACTOR NAME PHONE# Z CONTRACTOR ADDRESS .�_ �' � G��9�f ' CA LIC# -79,5-452 M676 INSURER fsC1C//: i✓ S £C . z/'✓z WORKER COMP#S71Tf- �FIRE DISTRICT C B - d rO PERMIT#COUNTY J PHONE LABORATORY NAME t� PHONE # SAMPLING FIRM TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT&PAST DATE INSTALLED 39- p 39- 39- 39- 39- 39- APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,FEDERAL LAWS.AND RULES AND ENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL FOLLOWING: 9 CERTIFY THAT IN THE PERFORMANCE E THE WORK FOR WHICH THIS PERMIT 15 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH S OF SA MANNER IGNATURE CE CTO BECOME SUBJECT ERTIFIES THE FOLLOWING 'I ERTIFY THAT N TKERS HE PERIFOO "ICE OFTHE CALIWORK FOR WHICH THIS PERMITS ISSUED,SHALLCTORS HIRING OR PERSONS SUBJECT TO WORKER'S COMPEN W F CAL FOR APPLICANTS SIGNATURE �fITLE C��,//Ci��Z DATE IL Q O`� APPROVED APP.ROVEDWITH CONDITIONS) ❑ DISAPPROVED _`.(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) . PLAN REVIEWER'S NAME v ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046(REVISED 3115102) Page 3 '