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ENVIRONMENTAL HEALTH DEPARTIi(�IVED SAN JOAQUIN COUNTY MAR 162015 APPLICATION FOR UNDERGROUND STORAGE TAWdVIRONMENITAL CLOSURE PERMIT HEAlm-irF:pA t m. F%m, THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: IZl REMOVAL fl TEMPORARY N ASI IRF I-1 RI ncI laG Im of Arc TANK INFORMATION`' TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED 39- S (/ % ©/L 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 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: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS.OF CALIFORNIA.' APPLICANT'S SIGNATURE �..��/.t-._/4 TITLE [ �I-%�!19,G/_/DATE U /'rrr-lu V.CU .t-%rrmV VC'U VVI I I'1 k.aunj L11'I R rsik'o) LJ: UITAFF'KUVbU' . f - (S,EE,CCOONDITI�ONNS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME IYMJ `\LiC:DATE.-a�-�� ANY DEVIATIONS FROM THIS' APPLICATION MUST BE'SUBMITTED ,TO EHD FOR APPROVAL:: PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 10/30/12) 3 FACILITY INFORMATION CONTRACTOR INFORMATION EPA SITE O JLi PROJECT CONTACT y 4( !1% PHONE# Z@ 2. i FACILITY NAME S i�� Srlwlc % PHONE # ZD %% Op " ADDRESS J lvete %y e'r4 o ¢ CROSS STREET OS G . CA LIC # OWNER OPERATOR (4 lthge-fX'A PHOWE # < r" TANK INFORMATION`' TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED 39- S (/ % ©/L 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 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: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS.OF CALIFORNIA.' APPLICANT'S SIGNATURE �..��/.t-._/4 TITLE [ �I-%�!19,G/_/DATE U /'rrr-lu V.CU .t-%rrmV VC'U VVI I I'1 k.aunj L11'I R rsik'o) LJ: UITAFF'KUVbU' . f - (S,EE,CCOONDITI�ONNS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME IYMJ `\LiC:DATE.-a�-�� ANY DEVIATIONS FROM THIS' APPLICATION MUST BE'SUBMITTED ,TO EHD FOR APPROVAL:: PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 10/30/12) 3 CONTRACTOR INFORMATION CONTRACTOR NAME i,,n/ >' (ri'/( /.1, PHONE # CONTRACTOR ADDRESS(n LO / G . CA LIC # S6 CLASS ! /iA INSURER fif/Q S(! WORKER COMP# T /z,7.tJ/ FIRE DISTRICT PERMIT# LABORATORY NAME (J t✓�L %�G- G COUNTY ' ( PHONE57 SAMPLING FIRM I PHONE# TANK INFORMATION`' TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED 39- S (/ % ©/L 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 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: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS.OF CALIFORNIA.' APPLICANT'S SIGNATURE �..��/.t-._/4 TITLE [ �I-%�!19,G/_/DATE U /'rrr-lu V.CU .t-%rrmV VC'U VVI I I'1 k.aunj L11'I R rsik'o) LJ: UITAFF'KUVbU' . f - (S,EE,CCOONDITI�ONNS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME IYMJ `\LiC:DATE.-a�-�� ANY DEVIATIONS FROM THIS' APPLICATION MUST BE'SUBMITTED ,TO EHD FOR APPROVAL:: PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 10/30/12) 3