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L 0 ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY APPLICATION FOR UNDERGROUND STORAGE TAN CLOSURE PERMIT THIS PERMIT FOR PERMANENT[TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUN AZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED A S. INDICATE PERMIT TYPE: MREMOVAL ❑ TFMPnPAPY CI ACI IRR n e'l CJ loo oL A^= TANK I ORMATION TANKID# TANK SIZE TANK ONTENTS PRESENT AND. PAS DATEINSTALL D 39-1 S IS ,,Z o obo / - t z 39- *IC'607 aoo L "SrL /yam„ 39-1 Of1 C2 cSr P�39- a 39-00 5PL,T i oc�9 r/39- 0 Nr /L.Z O APPLICANT MUST PERFORM ALL WORK IN ACC DANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAOUIN COUNTY E IRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFO MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO RKER'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 WORK COMPENSATION LAWS OF CALIFORNIA.' ton/ 71 APPLICANT'S SIGNATURETITLE_ CiG//✓�/� (il/EU) DATE �"Z 0 �> ❑ APPROVED PLAN REVIEWER'S ANY EH2Y046 (Revised 10/30/12) (SEE CONDITIONS BELOW -AND/OR ON MUST BE SUBMI D TO,F CONDITIONS: ❑ DISAPPRQVED ptN L/exr FACILITY INFORMATION EPA SITE#CAI) q 7PRQJECT CONTACT Z e - PHONE#2,o5 z 5 % FACILITY NAME'" )4 /S / PHONE # 2 e S 3 j %L ADDRESS / G/ (JS 6 /J CONTRACTOR ADDRESS CROSS STREET 4r,11,1 6 CLASS Z OWNER OPERATOR /'( 16 A PHONE #La` v%_ TANK I ORMATION TANKID# TANK SIZE TANK ONTENTS PRESENT AND. PAS DATEINSTALL D 39-1 S IS ,,Z o obo / - t z 39- *IC'607 aoo L "SrL /yam„ 39-1 Of1 C2 cSr P�39- a 39-00 5PL,T i oc�9 r/39- 0 Nr /L.Z O APPLICANT MUST PERFORM ALL WORK IN ACC DANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAOUIN COUNTY E IRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFO MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO RKER'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 WORK COMPENSATION LAWS OF CALIFORNIA.' ton/ 71 APPLICANT'S SIGNATURETITLE_ CiG//✓�/� (il/EU) DATE �"Z 0 �> ❑ APPROVED PLAN REVIEWER'S ANY EH2Y046 (Revised 10/30/12) (SEE CONDITIONS BELOW -AND/OR ON MUST BE SUBMI D TO,F CONDITIONS: ❑ DISAPPRQVED ptN L/exr CONTRACTOR INFORM ION CONTRAi 6. PHONE#ZO`' 6 /J CONTRACTOR ADDRESS j % , GJ .L CA LIC # 6 CLASS Z INSURER WO ER COMP#AFI /47 3 -/3 FIRE DISTRICT e T S ' P MIT# LABORATORY NA OUNTYST,Jif (qNs PHONE# 2J% % O SAMPLING FI M g G PHONE# 20 TANK I ORMATION TANKID# TANK SIZE TANK ONTENTS PRESENT AND. PAS DATEINSTALL D 39-1 S IS ,,Z o obo / - t z 39- *IC'607 aoo L "SrL /yam„ 39-1 Of1 C2 cSr P�39- a 39-00 5PL,T i oc�9 r/39- 0 Nr /L.Z O APPLICANT MUST PERFORM ALL WORK IN ACC DANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAOUIN COUNTY E IRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFO MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO RKER'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 WORK COMPENSATION LAWS OF CALIFORNIA.' ton/ 71 APPLICANT'S SIGNATURETITLE_ CiG//✓�/� (il/EU) DATE �"Z 0 �> ❑ APPROVED PLAN REVIEWER'S ANY EH2Y046 (Revised 10/30/12) (SEE CONDITIONS BELOW -AND/OR ON MUST BE SUBMI D TO,F CONDITIONS: ❑ DISAPPRQVED ptN L/exr