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0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEENVIRONMENTAL HEALTH S <br /> DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE; <br /> REMOVAL <br /> ❑ TEMPORARY CLOSURE ❑ CLOSURE'IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACTil, <br /> FACILITYNAME LI �� PHONE# <br /> ADDRESS PHONE# O <br /> CROSS STREET <br /> OWNEROPERATOR' IA)03 PHONE# <br /> n <br /> 1 f' <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME f I ry %CCS i7(I PHONE# <br /> CONTRACTOR ADDRESS CA LIC# / t CLASS 7 <br /> INSURER C Nn WORKER COMP# <br /> FIRE DISTRICT Itl PERMIT# ' <br /> LABORATORYNAME - I COUNTY PHONE <br /> SAMPLING FIRM PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39 U <br /> i <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT <br /> 9- <br /> 393939- <br /> 39- <br /> APPLICANT 41UST PERFORM ALL WORK M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN TOOWING: 'I <br /> BECOME <br /> THAT IN THE PERFORMANCE OF PE WORN COUNTY PUBLIC HEALTH <br /> FOR WHICH IAUF PERMIT ISCES, OWNER ISSUED,SSHALL NOT EMPLOY ANY PERSON N SUCH ED AGENT'$SIGNATURE CERTIFIES THE ALMANNER q5 <br /> TO BECOh1E SUBJECT TO WORKER'S COMPENSATION IAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING 'l CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION ISOFC IFORNIA.'� <br /> APPLICANT'S SIGNATURE TITLEV/YL� DATE <br /> ❑ APPROVED AVAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> 1 1 /' (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME Iti.NCA DATE (7'1 "07 <br /> + ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHO FOR APPROVAL PRIOR TO COMMENCING <br /> WORK-CONDITIONS: <br /> ' EH 23 046(REVISED 08/13199) Page 3 <br />