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SAN JC JUIN COUNTY PUBLIC HEALTH F 'RVICES <br /> ENVIRONMENTAL HEALTH DIVISIO., <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTfrEMPORARY 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 Cl CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#C L ' O PROJECT CONTACT Coeili3ig PHONE# <br /> 1 <br /> FACILITY NAME I PHONE#Qt'� .3b7 <br /> ADDRESS . O F S} E T <br /> CROSS STREET t 2 <br /> OWNER OPERATOR PHONE# R,Ocl) illq-0434 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME t< �" PHONE# '20 y /oa <br /> CONTRACTOR ADDRESS CA LIC# Lao?Z-7 CLASS <br /> INSURERocMna f WORKER COMP# /3 "7 - <br /> FIREDISTRICT ( IT ---jC STOC C F' E PERMIT# <br /> LABORATORa - COUNTY PHONE# -Zc3q-qfp ^plgq <br /> SAMPLINGFIRM C_ :C �,.a- L,C 1 PHONE It Zoq^ - Ors L <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- ! D O In c7.kv <br /> 39- i / 1 % - <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 PUSUC 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' <br /> APPLICANTS SIGNATURE TITLEkO C� IC I.^ DATE Ir3o--q$ <br /> ❑ APPROVED PPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME ��Q,S DATE a 7-9-y <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> Lt S c `d <br /> EH 23 0661 ED,I (J .e,a9(S!/lt LlN IJ `�- A <br />