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SAN JOJ JIN COUNTY PUBLIC HEALTH , _RVICES <br /> fHRMIENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> T <br /> FOR PERMANENTITEMPO RY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> TANK(S)EXPIRES 90 DAYS OM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> 13'REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE Y0001J PROJECT CONTACT U` A r;: �' PHONE# 701 •;" <br /> AME h 5DN CENT<.;� LLC_ <br /> ADDRESS (o q ",'j 7 <br /> CROSS STREET ', O..1 O Ac. <br /> OWNER OPERATOR ;- n"rR��.z.A'; 4, (, RI< Yr IPHONE# <br /> CONTRACTOR INFORMATION <br /> TRACTOR NAME (-6,4 ,r TO PHONE# <br /> NTRACTOR ADDRESS qo Tr r� � .i� 7;>:-> -F, 1`++- 'D CA LIC# r'j ;'j. CLASS ;1 �? (-{/{ <br /> SURER Rod Y u L S �rE WORKER COMP# N ( - - o- C)- I bi <br /> FIRE DISTRICT C iT- 0r 5E-r KT aAJ PERMIT# 06 <br /> LAB YNAME Ar P3[1 Ar.1A1 T, ,A._. COUNTY CONT (`o TA PHONE# e/? - -7 ,?- 1620 <br /> PLIN I (CA!( EG ('fi L `t PHONE # 613 -_:2 <br /> 'no G TANK INFORMATION <br /> TANK ID# NK SIZE TANK CONTENTS (PRESENT& PAST) DATE INSTALLED <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> 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 <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA,' <br /> r - <br /> APPLICANT'S SIGNATURE ��. ?-� - ' - TITLE .i A,` ` /���Ji ,'IMP , ^('. DATE <br /> ❑ APPROVED o,APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATEU�- <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHO FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> i n I CONDITIONS) <br /> Qu�r T N - <br /> Z J <br /> u�Jd kn _ w�X_ - <br /> w- <br /> 60 <br /> EH 23 046(REVISED 08/13/99) Page 3 <br />