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SAN JQQUIN COUNTY PUBLIC HEALTH =RVICES ENVIRONMENTAL HEALTH DIVISI / 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 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF E 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 PENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN 1YIE PERF MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF UFORN .' ,per �7 APPLICANTS SIGNATURE TITLE t e \. DATE f l/ L'I 9 ❑ APPROVED QAPPROVED WITH CONDITION(S) ❑ DISAPPROVED SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME i6 - L— --� �� '-- DATE�� ANY DEVIATIONS FROM THISkPPUCATIONMUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. 41„, �^ n _ CONDITIONS: A HAZ ASB C' FACILITY INFORMATION EPA SITE #C lop* PROJECT CONTACT PHONE# FACILITY NAME PHONE # ADDRESS CoMpany WORKER COMP# 007108-98 CROSS STREET { NX, , OWNER OPERATOR Me-( V f 1 S PHONE # C 4- _ZQ 1 (, APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF E 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 PENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN 1YIE PERF MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF UFORN .' ,per �7 APPLICANTS SIGNATURE TITLE t e \. DATE f l/ L'I 9 ❑ APPROVED QAPPROVED WITH CONDITION(S) ❑ DISAPPROVED SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME i6 - L— --� �� '-- DATE�� ANY DEVIATIONS FROM THISkPPUCATIONMUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. 41„, �^ n _ CONDITIONS: A HAZ ASB C' CONTRACTOR INFORMATION CONTRACTOR NAME SFMCO CONTRACTOR ADDRESS 1217 South PHONE # 209-524-9653 7th Street CA LIC# ¢¢9864 CLASS INSURER State FUnd Insurance CoMpany WORKER COMP# 007108-98 FIRE DISTRICT / -02_ PERMIT # LABORATORY NAME GeoAnal 1Ca1 COUNTYuS] PHONE # SAMPLING FIRM Geo l 1Ca1nqoo _ PHONE k 209 572-0900 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF E 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 PENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN 1YIE PERF MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF UFORN .' ,per �7 APPLICANTS SIGNATURE TITLE t e \. DATE f l/ L'I 9 ❑ APPROVED QAPPROVED WITH CONDITION(S) ❑ DISAPPROVED SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME i6 - L— --� �� '-- DATE�� ANY DEVIATIONS FROM THISkPPUCATIONMUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. 41„, �^ n _ CONDITIONS: A HAZ ASB C' TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- / -02_ ie c cv 61o, it U' -,d 4 Cu L-- 39- S --O �b vrro 6". 2 tU4&e' I, 39- _O z ooa �ccf , rewn , r I 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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF E 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 PENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN 1YIE PERF MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF UFORN .' ,per �7 APPLICANTS SIGNATURE TITLE t e \. DATE f l/ L'I 9 ❑ APPROVED QAPPROVED WITH CONDITION(S) ❑ DISAPPROVED SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME i6 - L— --� �� '-- DATE�� ANY DEVIATIONS FROM THISkPPUCATIONMUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. 41„, �^ n _ CONDITIONS: A HAZ ASB C'