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SAN J !AQUIN COUNTY PUBLIC HEALTS.6ERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> /THISRMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> E TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> e6EMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#GPC lZ PROJECT CONTACT teE-SPHONE#209-�(& -833 <br /> FACILITY NAME PHON WOW- jy& '9'D <br /> ADDRESS <br /> CROSS—STREET <br /> WN PERATOR PHONE# 0�� <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAM - PHONE fY' <br /> CONTRACTO ADDRESS A) O CA LIC# CIAS <br /> INSURER WORKER COMP# <br /> FIRE DISTRICT G c� PERMIT# _ <br /> LABORATORY NAME COUNTYSAMPLING FIRM I? /' PHONE # — O <br /> TANK INFORMATION <br /> TANK ID# A K SIZE TANK CONTENTS PR/ES'ENT�& PAST DATE INSTALLED <br /> 39-651557 / <br /> 39 7 <br /> 39- <br /> 39- <br /> 139- <br /> 139- <br /> APPLICANT <br /> 9-39-39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACGYRDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN CO TY P BUC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING' 'I <br /> CERTIFY THAT IN THE PERFORMANC F T E WORK FOR WHICH THIS PER IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER' C MP NSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I BDANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSA <br /> APPLICANT'S SIGNATURE _ __TITLE DATE-7'�I-0 / <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME Q/ DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITION ✓� C.cJ � b �� <br /> EH 23 046(REVISED 08/13199) Page 3 <br />