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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY 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 ❑ TEMPORARY CLOSURE ❑ CLOSURE'IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT C PHONE# - 5 <br /> FACILITY NAME LI - ;r& PHONE# Q <br /> ADDRESS <br /> CROSS STREET <br /> OWNER OPERATOR' �gJ"R/N/' ulddWd�'TPHONE# <br /> nodl A) sq17 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME C /{ ICCS I'1(1 PHONE# <br /> CONTRACTOR ADDRESS CA LIC# CLASS Q <br /> INSURER iC Un WORKERCOMP# <br /> FIRE DISTRICT B PERMIT# <br /> LABORATORY NAMEoeo Atu COUNTY PHONE# <br /> SAMPLING FIRMPHONE # <br /> TANK INFORMATION <br /> TANK IO# TANK SIZE TANK CONTENTS PRESENTS PAST DATE INSTALLED <br /> 39- <br /> -39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT <br /> 9- <br /> 39- <br /> 39- <br /> 39-39APPLICANT MUST PERFORM ALL WORK M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS.AND RULES AND <br /> REGULATIONS IN SAN PERFORMANCE <br /> COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES I THE FOLLOWING: S <br /> TOBECERTIFY THAT IN THE TO WORKERS <br /> OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SMALL NOT EMPLOY ANY PERSON SI SUCH A MANNER AS <br /> TO BECOME SUBJECT RT WORKERS COMPENSATION LAWS OF CALIFORNIA.' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING' '{CERTIFY THAT MI THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISBUEO,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LA S OF O/gRRNIA.' <br /> APPLICANTS SIGNATURTITL / & / / DATELM. .JJ <br /> fK.l <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) C� <br /> PLAN REVIEWER'S NAME TNG DATE 0'I -0J <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> C4--r, <br /> EH 23 046(REVISED 08113199) Page 3 <br />