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E,JVIRONMENTAL HEALTH DEPARTMENT APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENT/TEMPORARY 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 CONTACT �S !"�; `terI PHONE# 209 4L.-) 100(. FACILITY NAME Sc n Hell �arr� 'n PHONE# aL09 `167 /00(, ADDRESS 2.J 1/8 £. w Farri(i. }on CA 45.230 CROSSSTREET CRCw10.. Be %1,4 0.A OWNER OPERATOR &tn u:nt Tn✓e # CLC PHONE# 20q (,Ol ,2a2 CONTRACTOR INFORMATION CONTRACTOR NAME A&U&nGvir ne.c. Z PHONE# a09 4(n7 - 1006 CONTRACTOR ADDRESS 5.31 SAaw✓ RA CA LIC#GBDd„1-] CLASS h I44� INSURER S} 4-t Pj IWORKERCOMP# 7 7H-oc FIRE DISTRICT Farn .A 1-u ( & CG c,-1' PERMIT# LABORATORYNAME C&I T[U�\ COUNTY Om^ �e PHONE# S(r21723740 SAMPLING FIRM C-I I PHONE # (a'1 A71 a') U TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAS DATE INSTALLED 39- VST _ l IS0 un Known pup- v known 39- 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 ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOYANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO RKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWI G: 'PCERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S P SATIONN L�LAA'AW§OFC IFORNIA.' APPLICANT'S SIGNATURE (/ TITLE 1n4- f " 0.,.nc— DATE '5- 0 ❑ APPROVED DAPPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME �'�Un If1 p-, 1`�A L!MDATE 2,3 6L=J ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046(REVISED 10/16/03) Page 3 1. (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES[] NO[]