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SAN JOAr' 'IN COUNTY PUBLIC HEALTH SE`110ES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTlTEMPORARY 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 FACILITY INFORMATION EPA SITE#Ce4 c olu PROJECT CONTACT E h / PHONE# LOC' I FACY NAME .S, PHONE# Zp t ILff ADDRESS 14! d CROSS STREET i-:--A / ( C L OWNER OPERATOR Q L O PHONE#ZQ 9 C ? LZ CONTRACTOR INFORMATION CONTRACTOR NAME ( L PHONNE# LC Z CONTRACTOR ADDRESS C , /% CA LIC# l Ci C CLASS A i' i Z INSURER :[/ .v/ / L L/�✓L.� WORKER COMP# �Q // -U FIRE DISTRICT PERMIT# LABORATORY NAME C,Fo,4L /G COUNTY _ PHONE# '9 SJL 0-2O6 SAMPLING FIRM L PHONE # )_p )Z O C C TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS(PRESENT 8 PAST) DATE INSTALLED 39- 39- 62.0 0 !i( ! / 39- 39- 39- 39- APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACUIN COUNTY ORDINANCES,STATE LAWS. FEDERAL LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR UCENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: '1 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 COMPENSATON LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TME 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 CAU F IdIA.' APPLICANTS SIGNATURE 'G TITLEDATE � 04 nS ❑ APPROVED E2-APPROVED WITH CONDITION(S) ❑ DISAPPROVED � J�� (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) T(�/' PLAN REVIEWER'S NAME ` DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046(REVISED 10/19/98) Page 3