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SAN J1_1QUIN COUNTY PUBLIC HEALTH - :RVICES ENVIRONMENTAL HEALTH DIVISIN 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# L'QQ 2 PROJECT cowAcTAR98 fiRWlcjDPHONE# 2 FACILITY NAME G T OjcL PHONE#Zf/ a L ADDRESS (5 q) r vrL' ME CROSS STREET Cf 7W $ 4 OWNER OPERATOR ( 41 r L'6 PHONE#z OL CONTRACTOR INFORMATION CONTRACTOR NAME /,,77 Y L- , I PHONE#Z CONTRACTOR ADDRESS Al i3sct-,00,,o -lela. CA LIC# 3� o CLASS L INSURER Cj WORKER COMP#$�49 -O FIRE DISTRICT C! r Qx'c PERMIT# (/�pn) LABORATORY NAME 4 9 (� COUNTY PHONE# B - S 7Z G 00 SAMPLING FIRM L 1 PHONE It 2p p d TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT 8 PAST) DATE INSTALLED 39- 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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: -1 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 CAUF RNW' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTFIES THE FOLLOWING: 'I CERTIFY THAT IN F !9S OF THE K FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS CA F RNIA' APPLICANTS SIGNATURE TITLE M DATE ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED AA (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME 1./`.,�. n(��. DATE '22_1)7 ( ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK, / L CIIONDITIONS: EH 23 046(REVISED 10/19/98) Page 3