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i SAN J/ QUIN COUNTY PUBLIC HEALTH ' VICES ENVIRONMENTAL HEALTH DIVISK74 APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE T (S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: OVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE SCA600 30-T PROJECT CONTACT IPHONE#Zo9- 6//-$',333 FACILITY NAME _ - IA-I�( PHONE ADDRESS S /`7e. HqST CROSS STREET OWNER OPERATOR ,j PHONE#T_o91ti S6- CONTRACTOR INFORMATION CONTRACTOR NAME i q IIF4E" PHONE#Z41-11611-6-933 CONTRACTOR ADDRESS o• �-- I CA LIC# 1 CLASS C-6/ O INSURER DA12 WORKER COMP#8016 Z- FIRE DISTRICT PERMIT# LABORATORY NAME 14 clf4 ac-LL- uri- COUNTY q&,CM PHONE#S/25-795- Z Z0 SAMPLING FIRM Ep1p1.tE,v PHONE k 2-o4- 6 - O 0 TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS(PRESENTS PAST) DATE INSTALLED 39- 12 1 �S'O Asp 39- 39- 39- 39- 39- APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. FEDERAL:AWS.AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR UCENSED AGENTS 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 C MPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWIIJG: 'I CERTIF/THAT IN E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPE ONLAW FORM APPLICANTS SIGNATUR - TTTLElj',ON`«-f DATE 3—iE—O / ❑ APPROVED XAPPROVED WITH CONDITION(S) C DISAPPROVED .�, ,[, ((SEE�E CONOITIONS BELOWAND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME// / /�v 1[/"Z�-L77�� DATE .Q=Q ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHO FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: I ¢ c w� 11 C ' E. 23 04fi (R c{� 10/1 Page