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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 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 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: 18I REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE GA0-0 FACILITY INFORMATION EPA SITE# PROJECT CONTACT .t J ' PHONE# '2001 • .-$V.S- FACILITY NAME r l PHONE#' ADDRESS 3ZQ p) t., r CROSSSTREET A.z C OWNER OPERATOR PHONE# - '(o, CONTRACTOR INFORMATION CONTRACTOR NAM s- - — PHONE# CONTRACTOR ADDRESS .lj -- x '7 t 1,irl CLASS Ni INSURERS-V-y,,-jq ' WORKER COMP# ti - -, it FIRE DISTRICT PERMIT lb LABORATORY NAME K( YL COUNTY Yn In I PHONE# 'O oo SAMPLING FIRM - - PHONE# TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED 39- O o 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 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME U JECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FIPLLPWING: CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT T RKE4S0M,,NSATION LAWS OF CALIFORNIA'APPLICANT'S SIGNATURE '� . ��. TITLE C our'-VI" :CD Ir DATE 2+"'ZL'•11 ❑ APPROVED ® APPROVED WITH CONDITION(S) ❑ DISAPPROVED ,N� ^^ ((SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) A PLAN REVIEWER'S NAME l - Nr'l�yr-)� DATE 3 !� ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIO S: EH 23 046 (Revised 07/22/10) 3