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SAN JOIN COUNTY PUBLIC HEALTH VICES <br /> JO* <br /> VIRONMENTAL HEALTH DIVIS1077 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # PROJECT CONTACT PHONE# <br /> FACILITY NAME U PHONE# .L <br /> ADDRESS D I p , <br /> CROSS STREET t F l Z- ANC, <br /> OWNER OPERATOR b PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME PHONE# �j <br /> CONTRACTOR ADDRESS 10 oQQECA LIC# 6 j'"CLAS's <br /> INSURER WORKER COMP# <br /> FIRE DISTRICT PERMIT# <br /> !LABORATORY NAME COUNTY ftj PHONE# <br /> SAMPLING FIRM PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- 003 <br /> 39- <br /> 39- - <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING. 'I <br /> 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 <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING 'I CERTIFY TH.AR IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAW OF CALIFORNIA," <br /> APPLICANT'S SIGNATURE TITLE01"'' DATE <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> ov <br /> EH 23 046(REVISED 08/13/99) age 3 <br />