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SAN JO. UIN COUNTY PUBLIC HEALTH SF /ICES Ik Cof"y <br /> ENVIRONMENTAL HEALTH DIVISION 1 7 <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# CAL oo., PROJECT CONTACT -r, C I PHONE# -ZoG- -7-100(o <br /> 20 <br /> FACILITY NAME ',5 � PHONE# --1.37-o <br /> ADDRESS I W IDO n <br /> CROS"TREET AD <br /> OWNER OPERATOR q" A PHONE# c7- 2yy - 2-370 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME AAQ A NCQD GQ n EA.I rNVn PHONE# D <br /> CONTRACTOR ADDRESS tino 5 NeA714150 .Q CA LICIV 22'7 C1A55 <br /> INSURER c O Jo— Q� pn S , WORKER COMP# I 7 <br /> FIRE DISTRICT f PERMIT# /1 <br /> LABORATORY NAME L'C 1 S 1 ti N r` "'e C COUNTY S AN j x,, �� PHONE# 2, --III <br /> q Z. <br /> SAMPLING FIRM CC p n ?QC 1 PHONE # 1.0 _ _ <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT 8 PAST) DATE INSTALLED <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 16 <br /> 9-39- <br /> 39- <br /> 39- -- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS. FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING. -1 <br /> 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 <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' l <br /> APPLICANTS SIGNATURE ` 41 Pi 6 A., TITLE PRO' r [ 'f �PN O !» DATE -30" 9 <br /> ❑ APPROVED IYAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME — DATE I " 'i <br /> ANY DEVIATIONS FROM THIS APPLICATION M ST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> � - — <br /> EH 23 046(REVISED 10/19/98) Page 3 <br />