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SAN JC WIN COUNTY PUBLIC HEALTH S' VICES <br /> ENVIRONMENTAL HEALTH DIVISKkf <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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> 8'R'EMOVAL Cl TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT PHONE# C7 <br /> FACILITY NAM PHONE# <br /> ADDRESS <br /> CR S STREET <br /> OWNER ERATCR Up I ^00F2I ?HONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAM i-® PHONE#- D <br /> CONTRACTOR ADDRESS l CA LIC# O CLAS <br /> .NSURER I WORKER COMPS Q Z. <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME G COU PHONE# Z <br /> SAMPLING FIRM PHONE % (o 100 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- ISSO-D I a om <br /> j39- 1g - Z 4 o <br /> 39- 13fo-o3 <br /> 39- (9 -b4 to <br /> 39- l83(0- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORKiN ACCORD NCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC TH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> CERTIFY THAT IN THE PERFORMANCE O THE WO FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO 'S C PENSA LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTI T F THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION CA FORMA.' <br /> APPLICANTS SIGNATURE TITLEIlkc e-, _OATE/z--7J <br /> C APPROVED PPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> `I /� (IEE CONOIITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME NlSt)V1 VDyyyl 91Comcl DATE_2 ag-:� <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> QRAd v) USA S <br /> r <br /> g <br /> E� 22 046(REVISED i 0/19/98) Page 3 <br />