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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVI )N APPLICATION F -,-,R UNDERGROUND STORAGE Tt• —K CLOSURE PERMIT THIS PERMIT FOR PERMANENT,r(EMPOP.ARY 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' 'M REMOVAL�❑TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION CONTRACTOR INFORMATION EPA SITE # PRWECT CONTACT f !S CONTRACTOR NAME LC-- , 1 PHONE TrS`J `fit tl d 7=�G' CA LtC CONTRACTOR ADDRESS 5S 2 7 N •- # 7�' fir-/ y LCLASS J1 �'I Z M FACILITY NAE C,.; A V � +Z Lz- `' .S A E PHONE # 1 `� 3 i ADDRESS tt 3 /,5- E_ 14-4 FIRE DISTRICT CROSS STREET A '_Q ' C,hfis�,I,�,�` OWNER OPERATOR E a%jy A E fDzy e' , r'� T� i PHONE : SLS- 7 (,^6, - 3zi -93 APPLICANT 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 OF, 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 COMPENSATfON LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE( ' 1••% - �r ` TITLE SF�ZL'�"c =_ �=Lh4 DATE , 1 _t) ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ElDISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHE) FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: CONTRACTOR INFORMATION CONTRACTOR NAME LC-- , 1 PHONE TrS`J `fit tl d 7=�G' CA LtC CONTRACTOR ADDRESS 5S 2 7 N •- # 7�' fir-/ y LCLASS J1 �'I Z INSURER WORKER COMP# `Lati C FIRE DISTRICT PERMIT # C,hfis�,I,�,�` LABORATORY NAME COUNTY PHONE # SAMPLING FIRM 1��\ fti %� PHONE # j/c� tjZ`? ,- 3 �3'�"l APPLICANT 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 OF, 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 COMPENSATfON LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE( ' 1••% - �r ` TITLE SF�ZL'�"c =_ �=Lh4 DATE , 1 _t) ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ElDISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHE) FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: TANK tNFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- ) �� C,hfis�,I,�,�` �2- 9 39- C,�tsvl','N_ tZ -910 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 COUNTY PUBLIC HEALTH SERVICES, OWNER OF, 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 COMPENSATfON LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE( ' 1••% - �r ` TITLE SF�ZL'�"c =_ �=Lh4 DATE , 1 _t) ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ElDISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHE) FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: