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SAN JOAQUIN COUNTY <br />E`,'IRONMENTAL HEALTH DEPARI,,,,:NT <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT F.QR PERMANENTlTEMPORARY 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 />❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />"A I Iow(Vz-APC. Y/vu:2�tAaza'/J - c:-vy-`�c:� <br />TANK INFORMATION <br />FACILITY INFORMATION <br />CONTRACTOR INFORMATION <br />EPA SITE # <br />PROJECT CONTACT M arlC rj4(,, <br />PHONE# '�l4l 8"l'1—Zr �'CE <br />FACILITY NAME <br />^I FIrS du frmf <br />PHONE# ql -?364 <br />ADDRESS $ 1 <br />un 'oi'UL <br />PR(KC <br />CROSS STREET <br />r <br />CLASS f Nla7- <br />OWNER OPERATOR <br />r 5 / U <br />PHONE # 209 4 411-1?16 <br />"A I Iow(Vz-APC. Y/vu:2�tAaza'/J - c:-vy-`�c:� <br />TANK INFORMATION <br />TANK ID # <br />CONTRACTOR INFORMATION <br />39- <br />ew, r 0 L( n yawn <br />CONTRACTOR NAME L nv r n <br />n <br />ter Enc, PHONE # <br />/ X <br />-667 —2 3 00 <br />CONTRACTOR ADDRESS Sol <br />PR(KC <br />i /' t n Aye. CA LIC# A#R=F-7'1 <br />26} I <br />CLASS f Nla7- <br />INSURER 57kfC-, <br />ru(' <br />WORKER COMP# 41C -07 <br />& -9 - <br />FIRE DISTRICT ori : bj <br />PERMIT # <br />LABORATORY NAME C. j I "-'A <br />a <br />p I//ct COUNTY PHONE # <br />1'16 <br />-6 3 it - }3 0 <br />SAMPLING FIRM o c <br />r4./� <br />PHONE q <br />"A I Iow(Vz-APC. Y/vu:2�tAaza'/J - c:-vy-`�c:� <br />TANK INFORMATION <br />TANK ID # <br />TANK SIZE TANK CONTENTS PRESENT & PAST DATE INSTALLED <br />39- <br />ew, r 0 L( n yawn <br />39- <br />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 ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br />FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH <br />A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING <br />SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY <br />PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br />APPLICANT'S SIGNATURE <br />TITLE VicPi DATE 17 -Il -Z461 <br />❑ APPROVED APPROVED WITH CONDITION(S) 11DISAPPROVED <br />(SE NDITIONS BELOW AND/OR ON ATTACHMENT) <br />l <br />PLAN REVIEWER'S NAME DATE <br />ANY DEVIATIONS FROM THIS APPLICATION MUSTVE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING ORK. <br />DITIONS <br />EH 23 046 (REVISED 3/75/02) Page 3 <br />