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UBLIC SAN 1L RVICE*NVIRCOUNTY AHEALTH DIVI 11LE COry 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. 21 REMOVAL(R1aNGE C.Ncj) ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE#CAD 9 la l qp PROJECT CONTACT PHONE .4►S) - i FACILITY NAME P6y4F- '5TtX+eTb S PHONE ADDRESS C] g CROSS STREET SI � OWNER OPERATOR PHONE# Z c, CONTRACTOR INFORMATION CONTRACTOR NAME EGKykqMrPHONE Zpoj CONTRACTOR ADDRESS ,O CA LIC#3o9lO5 i INSURER WORKER COMP# 4j FIRE DISTRICT �.' �_ PERMIT# LABORATORY NAME �AFAeU_ COUNTY PHONE#S'/6- - �.Z SAMPLING FIRM -PHONE # -#(20r-loo TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS (PRESENT& PAST) DATE INSTALLED 39- 1 I a ocick u 39- 39- 3'9- 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 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 SUBCCNTRACTING 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 CALIFORNI " _ d m4k APPLICANT'S SI ATURE TITLE PRp 3E4=T- t_1�*Ab,GEZ- DATE I OA-7 hfno T mp nH h1 G - VFo22- ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME (. '' DATE V 136/ ANY DEVIATIONS FROM THIS APPLICATION MUST RE S 8 ITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046(REVISED 08113199) Page 3