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EI..iRONMENTAL HEALTH DEPARTMO APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: [�REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# PROJECT CONTACT PHONE# FACILITY NAME PHONE# ADDRESS CROSS STREET HA. OWNER OPERATOR Ppvl PHONE# V CONTRACTOR INFORMATION CONTRACTOR NAME P PHONE# CONTRACTOR ADDRESS p CA LIC# CLASS INSURER ^- L WORKER COMP# p FIRE DISTRICT PERMIT# LABORATORY NAME of L, L COUNTY ' —5 -T G I PHONE# / - - SAMPLING FIRM U sa C, PHONE # TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED 39— . 39—-L. c, 8.4 39- V9.1 H 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: "I 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE LIC % �— TITLE A4,941 DATE/> ❑ APPROVED 13 APPROVED WITH CONDITION(S) ❑ DISAPPROYED (SEE,COND ONS BELOW AND/OR ON ATTACHMENT) I PLAN REVIEWER'S NAMEA! DATE ANY DEVIATIONS FRdM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING�IVORK. \ j CONDITIONS: EH 23 046(REVISED 10/16/03) Page 3 1. (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES[] NO[]