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ENVIRONMENTAL HEALTH DEPARTMENT 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 c4e- oo Z S f/ O 53 FACILITY INFORMATION EPA SITE#6f If 0 02-!57 701ROJECT CONTACT FFR S PHONE# 20' 3 FACILITY NAME Alo,17W 444. IPHONE# ADDRESS 171c . CROSS STREET G2 OWNER OPERATORA''1 PHONE# 3 CONTRACTOR INFORMATION CONTRACTOR NAMEPHONE# S CONTRACTOR ADDRESS D CA LIC# CLASS INSURER //J .0 %f .J CL • f WORKER COMP# 7 %,/l7 G 7// 3'O FIRE DISTRICT C/f I PERMIT* NPOAJ /} /L C7//-R C LABORATORY NAME �(J' L COUNTY S'A.a.x�47✓/ PHONE# 2d r9 S'jL0 SAMPLP 1 PHONE # 2-050 TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAS 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 ENVIRONMENTAL HEALTH DEPARTMENT. 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 CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CER Il6X T INM/Z E OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENN LA '�APPLICANT'S SIGNATURE 'LTLE ❑ APPROVED ErAPPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) `l PLAN REVIEWER'S NAME`DE%�'�'r:�- �'p�'�'�y'�G DATE y ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046(REVISED 10/16/03) Page 3 1. (a) Is there a EHD contractor's and subcontractors questionnaire on file or enclosed? YES [] NO[]