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C.F EARONMENTAL HEALTH DEPARTM•
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<br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT
<br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES
<br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL RATE.'DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE:
<br /> ® REMOVAL ❑ TEMPORARY CLOSURE . ❑ CLOSURE IN PLACE
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<br /> EPA SITE# G RD9B 1*690014 PROJECT CONTACT PWONE# (e
<br /> FACILITY NAME PG E O CrL'TO� � t CE PHONE# �'-t(e
<br /> ADDRESS Lop
<br /> CROSS STREET $pt]2gCa1.1 S ^�
<br /> OWNER OPERATOR M S PHONE# (Z_Dg) 9 4
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<br /> CONTRACTOR:INFORMAT. ON ' `.rvt��,�;
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<br /> CONTRACTOR NAME %S O MEC AW%CAL. I =9C• PHONE#(I5%Q)&j474Rej90
<br /> CONTRACTOR ADDRESS tW 1.&S ST. t.! item CA LIC#Co O CLASS L
<br /> INSURER WORKER COMP# L'"T t 4 S4-7 O'3 M t e_
<br /> FIRE DISTRICT C ICy F T C(]t.1 PERMIT# 'MD
<br /> LABORATORY NAME PPr_NEc O COUNTY G ,C.. PHONE# 19 8—lto'LD
<br /> SAMPLING FIRM {„p G PHONE R O q-fo 8Cn'T
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<br /> ANK.INFORNITION:�Y:«.. .. �:�� :t.. {:=. �u{; �.� �.�: �:
<br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT 8 PAST DATE INSTALLED
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<br /> 39 , E 70i
<br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.FEDERAL LAWS,AND RULES AND
<br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED.AGENT'S SIGNATURE CERTIFIES THE
<br /> FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH
<br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING
<br /> SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY
<br /> PERSONS SUBJECT TO WORKER'S MPENSATION LALIFORNIA.'
<br /> APPLICANT'S SfGN E TITLE 1P7a3-ECX DATE 17-Ig
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<br /> DEVIAT70NS FROM THIS APPLICAT_IOWM)LIST BE.SUBMITTEO TO EHD FOR?APPROVAL PRIOR.TOrCOMMENCING WORK.l-=u
<br /> CONDITIONS
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<br /> EH 23 046(REVISED]0/16/03) Page 3
<br /> 1. (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES [] NO[]
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