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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR-r4ENT 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 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: *REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# PROJECT CONTACT 6 i I PHONE# FACILITY NAME (A PHONE# Io(e- ADDRESS a CROSS STREET A Lam. OWNEROPERATOR I PHONE# CONTRACTOR INFOR ATION CONTRACTOR NAME WJP-- - L ff-� L PHONE#(53M CONTRACTOR ADDRESS (p I CA LIC# SQ CLASS INSURER - D WORKER COMP# (p FIRE DISTRICT -MA< PERMIT# P-U Oa y LABORATORY NAME ANT COUNTY 60f I PHONE# — SAMPLING FIRM , , q PHONE #(7071 TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS fPRESENT& PAST DATE INSTALLED 394RSIDd -5'Q(76-AL- Cate F,rbl L P 6 1974 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKS OMPEN WSOFCALIFORNIA.- APPLICANTS SIGNATURE TITLE ATE */�� ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046(REVISED 3/15/02) Page 3