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I4VIRONMENTAL HEALTH DEPARTMOT APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT SUBSTANCE THIS PERMITSTORAGE TANKO 5)PEXPIRES 90 DAYS FROM THEA PROVAL DATE.OTE DO NOT WRI IN OFANYSHHADEDOUND AREAS NI D CAOTESPERM T TYPES REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# PROJECT CONTACT NI.'�� `� ""A � PHONE#2O`(• 3 3707 /� PHCNE# 'LU BL dbzZ FACILITY NAME t' ADDRESS 3 4 e&I-T H `7 r ' i�C CA �t✓ ' CROSS STREET Sc�nfi -\40" hk C`0"'�� PHONE# � 4 ro 6 2 2- OWNER OPERATOR ktJ'-4 KOWN CONTRACTOR INFORMATION CONTRACTOR NAME M C -TNe, PHONE# 2J. ,4! 1,500 CONTRACTOR ADDRESS b(044R f vj CA LICS A INSURER J i V 5 mil ti� �I ES WORKERCOMP# '�ti IC AN► '[ I �s_ FIREDISTRICT 6:2—IJfv1If\ PERMIT# LABORATORY NAME PR �t�N �� - COUNTY 5A'f�l 4C C %:ff� PHONE# ��l ' `��7 SAMPLING FIRM ktak- 4. );C- C " PHONE ;# 20 .3L ' G I L Z.c: 7' TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED 39- © Z p 39- Z 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: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING` "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATIONLAWSOF CALIFORNIA." �- "\-��,. LE � DATE APPLICANT'S SIGNATURE �`- V ❑ 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 EHO FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 048(REVISED 10116103) Page 3 �� 1. (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES NO�]