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SAN JOAQUIN COUNTY PUBLIC HEALTH c"RVICES `,A\IVIRONMENTAL HEALTH DIVISIO.( .APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTfTEMPORARY 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: C'REMOVAL ❑ TEMPORARY CLOSURE Cl CLOSURE IN PLACE FACILITY INFORMATION PP OVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) DAT MU BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. � CONDITIONS: CONTRACTOR EPA SITE # CIV 3 13 PROJECT CONTACT / PHONE# - FACILITY NAME /(31 PHONE i,�-(,- CONTRACTOR ADDRESS 1217 ADDRESS qj}' c7sr 177s, S %2R'C_ S3 7th Street I CALIC# 449864 CROSS STREET Al. (L'f INSURER State Fund Insurance Company OWNER OPERATOR PHONE # 2 8"-5D70 TANK INFORMATION TANK ID # TANK SIZE TANK CONTEWS ('PRESENT & PAST) DATE INSTALLED 39- _ 6 °fa opo ILo L /99 L/ 39-_�:-6 S 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: '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 WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN jjHHE PERFORMANCE OF THE t RK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAIyS�F/CAUFO NIA.' n / / A APPLICANTS SIGNATURE TITLE A456'rr "'L- 6&j'U6'L-- DATE 2'&/CO ❑ APPROVED .PLAN REVIEWER'S NAME -ANY DEVIA IONS FROM THIS APPCATION /J � PP OVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) DAT MU BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. � CONDITIONS: CONTRACTOR INFORMATION CONTRACTOR NAME SEMCO IPHONE# 209-524-9653 CONTRACTOR ADDRESS 1217 South 7th Street I CALIC# 449864 CLASS 1 INSURER State Fund Insurance Company WORKERCOMP# 007108-98 FIRE DISTRICT PERMIT* LABORATORY NAME GeoAnalVtiCal I COUNTY Stanislausl PHONE #s72-nqnn SAMPLING FIRM GeOAnaj ticaj IPHONE# 209 572-0900 TANK INFORMATION TANK ID # TANK SIZE TANK CONTEWS ('PRESENT & PAST) DATE INSTALLED 39- _ 6 °fa opo ILo L /99 L/ 39-_�:-6 S 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: '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 WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN jjHHE PERFORMANCE OF THE t RK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAIyS�F/CAUFO NIA.' n / / A APPLICANTS SIGNATURE TITLE A456'rr "'L- 6&j'U6'L-- DATE 2'&/CO ❑ APPROVED .PLAN REVIEWER'S NAME -ANY DEVIA IONS FROM THIS APPCATION /J � PP OVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) DAT MU BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. � CONDITIONS: EH 23 046 (RFVI..Rrn in/1a/am--- A HAZ ASB C`