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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: C6REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE#G COV 2- PROJECT CONTACT PHONE# .$Jf FACILITY NAME T E C/T OC O / PHONE# 7 ADDRESS %Q S CROSS STREET OWNER OPERATOR / S 6K72 - PHONE# 7 .3 CONTRACTOR INFORMATION CONTRACTOR NAME c7le 1146, IPHONE# 3SSL CONTRACTOR ADDRESS Q 3S7 CA LIC# 6 CLASS 72 INSURER % T -C, / WORKERCOMP#SS;!;jl7 / FIRE DISTRICT C-/ O reek%.J PERMIT# (/ iZOC/ LABORATORY NAME64,3 1 COUNTY lW L PHONE# S L Z 72-2_7 SAMPLING FIRM $re ,419z .l—/ I PHONE# Z- 9 O TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT& 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 ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I 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 W RIfEFYS--CCOMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: C TIFY THA�IN THE NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL EMPLOY PERSONS SUBJECT TO WORKER' O PENSATI EE 8'�F . LIFOR A.' ••JJ APPLICANT'S SIGNATURE TITLE G1iLJ�/CgGlO/C, GATE ❑ APPROVED APP OVED WITH CONDITION(S) 11DISAPPROVED (SE COI 1 IONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE 1 ANY DEVIATIONS FROM THIS APPLICATION MUST BE Sd6MITTFD TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 12/31/07) 3