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SAN JOA^UIN COUNTY PUBLIC HEALTH SERVICES <br /> _ Lti.✓IRONMENTAL HEALTH DIVISION <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 /> XREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> _ EPA SITE 0C o PROJECT CONTACT C• PHONE# 1 - <br /> FACILITYNAME s PHONE Qr'1 3�7 <br /> ADDRESS d t . F r $} E T <br /> CROSS STREET 1 tF <br /> OWNER OPERATOR <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME 6 Q o 1 I PHONE# (Z O Y I oo <br /> CONTRACTOR ADDRESS Q . V 'I I CA LIC# j 2 CLASS <br /> _ INSURER CgSSj I WORKER COMP# If 31-7q S <br /> FIRE DISTRICT C; r � STo( KTcn SEE ''F I PERMIT* <br /> LABORATORY NAME CSC 1 Com."c - Trc#4 COUNTY iT A jcA,cPHONE# ZO -YE ' OFa aI Z <br /> SAMPLING FIRM C� 'C �•.o. L.Q PHONE # Loll- - CS' L <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39— l I 1 7 —o Ia^� <br /> 39- ( —6-1- <br /> 39- <br /> 139- <br /> 139- <br /> 39- <br /> APPLICANT <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: '1 <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' �I/.,t�1 //` f� <br /> APPLICANTS SIGNATURE L TITLE ! K O FC 1 �+�c/C5-;$I DATE II'-�C'--�L7 <br /> ❑ APPROVED IXAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM IS APPLICATION MUS BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> / { G a <br /> oC "-.) T1 6 - L" <br /> i <br /> EH 23 046(REVISED i /98) Page 3 <br />