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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S)EXPIRES 160 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: '19 REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE i FACILITY INFORMATION EPA SITE# PROJECT CONTACT PHONE# FACILITY NAME PHONE ADDRESS CROSS STREET rodl OWNER OPERATOR � -�- I PHONE# - O CONTRACTOR INFORMATION CONTRACTOR NAMEPHONE# CONTRACTOR ADDRESS CA LIC#' C S INSURER WORKER COM P# FIRE DISTRICT a PERMIT# LABORATORY NAME CA J_ COUNTY PHONE# SAMPLING FIRM PHONE# TANK INFORMATION TANK ID# TANK SIZE TANK CONT TS PRESENT AND PAST DATE INSTALLED # / 39' 8/ 8 L-3 1 000 -c9Lx- 00 #Z 39- 8/8a,�L 39- 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 ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S 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 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING 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 ER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANTS SIGNATURE TITLE`pU Ldk!�FinV .nC- DATE 2 ❑ APPROVED PPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE COND S BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLI'C�p J MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 10/30/12) 3