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RECEIVE[* fR 17 2017 i L j 17 2017 ENVIRONMENTAL HeAt' � i PARTM Zk'E A TMAL ENT 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 180 DAYS FROM TH APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: ❑ REMOVAL TEMPORARY CLOSURE ❑ CLOSURE IN PLACE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COAA`QIWPrNSATION NVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •i CERTIFY THAT IN TMERMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECWORKER'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWCERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORLAWS OF CALIFORNIA' APPLICANTS TITLE PO.OT _ M A aA66/i. DATE - o • I ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 7/26/2016) 3 TANK INFORMATION FACILITY INFORMATION CONTRACTOR NAME EPA SITE # PHONE # 1oZte - If 7,4 • px I PROJECT CONTACT S� 11 60 J 5'1 PHONE# `15 I - S Z Z - 5110 FACILITY NAME d- G F Q.6 1 GIA i PHONE # ADDRESS ISIS E. F•Esam n6z.o JE T 2A GM I-j/A CROSS STREET t�1 L IIlL NJ I PHONE # OWNEROPERATOR 4V-(. 'FG61bt4-r PHONE# 20 $33- 1300 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COAA`QIWPrNSATION NVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •i CERTIFY THAT IN TMERMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECWORKER'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWCERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORLAWS OF CALIFORNIA' APPLICANTS TITLE PO.OT _ M A aA66/i. DATE - o • I ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 7/26/2016) 3 TANK INFORMATION CONTRACTOR INFORMATION CONTRACTOR NAME C- (o YL S PHONE # 1oZte - If 7,4 • px I CONTRACTOR ADDRESS S 114 II h rL4 VLESIC (GO u )N Alk CA LIC # Sol Lo I to I CLASS INSURER P FS 1145 U ILA /aCrZWORKER COMP# H O Z 41 -1 O FIRE DISTRICT 39- PERMIT. LABORATORYNAME I-j/A COUNTY PHONE# SAMPLING FIRM PHONE # APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COAA`QIWPrNSATION NVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •i CERTIFY THAT IN TMERMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECWORKER'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWCERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORLAWS OF CALIFORNIA' APPLICANTS TITLE PO.OT _ M A aA66/i. DATE - o • I ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 7/26/2016) 3 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED 39- Isla tre*a ,L &1-t.. 39- T oz4919 10;0" (,c.Uy 011. IZ- t .1990 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 COAA`QIWPrNSATION NVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •i CERTIFY THAT IN TMERMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECWORKER'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWCERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORLAWS OF CALIFORNIA' APPLICANTS TITLE PO.OT _ M A aA66/i. DATE - o • I ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 7/26/2016) 3