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S e4 JOAQUIN COUNTY PUBLIC HEALTISERVICES ENVIRONMENTAL HEALTH DIVISION f APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT` "I THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERD-H&*RDQU1IS UB$T,PANCES STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHAD AX: S. INDICATi6 P A E: I>,dREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# PROJECT CONTAC I PHONE# 00 775-624 FACILITY NAMEw ADDRESS � SO n CROSS STREET � OWNEROPERATOR - �T PHONE# CONTRACTOR INFORMATION CONTRACTOR NAME 1 c- ' - PHONE# SO CiS2-555 I CONTRACTOR ADDRESS 3S CALIC# CLASS INSURERRICT F WORKER COMP# FIRE DISTPERMIT# - LABORATORYNAME - -NV,ROt, K COUNTY i . PHONE# 5RO- S SAMPLING FIRM PHONE # S - O TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED 39 A0505113 V24000 SO E a - —39- 0-5051 T '20,000 +c i• !r 39- 39- 39- 39- APPLICANT 939- 3939APPLICANT 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: '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: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATIOV4*1 S OF CAUFORNI ' APPLICANT'S SIGNATU TITLE ATE ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PI AN REVIEWER'S NAME DATE R-0 i ANY DEVIATIONS FROM THIS APPLICATION MUST BVSLYBMITTEO TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: 1 IPA cla EH 23 046 lREVISED 08/13199) Page 3 + �p