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SAN JOAQUIN COUNTY PUBLIC HEALTH F-RVICES 41VIRONMENTAL HEALTH DIVISIOd APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTITEMPORARY 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: REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# PROJECT CON I PHONE# dg- 01 FACILITY NAME r IiC., { I PHONE# ADDRESS A CROSS STREET ` OWNER OPERATOR PHONE# CONTRACTOR INFORMATION CONTRACTOR NAME r PHONE#MD CONTRACTOR ADDRESSCA LIC# p CLASS A"L INSURER WORKER COMP# FIRE DISTRICT PERMIT# LABORATORY NAME v COU NTYPHONE# 9 SAMPLING FIR PHONE # TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS(PRESENT 8 PAST) DATE INSTALLED 39- L4.n 39Ir - 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 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS/G&CCALIFORNIA.' APPLICANT'S SIGNATURE TITLE DATH9� tZ-^9� ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: 10 VK- 0CLUCA,"04 3 S I t W 11 T. 314 (R V ED,(Q�/).i�(NlX- LYA11. CLt.�(.QYL" Olh lr' ��