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SAN JC"- IN COUNTY PUBLIC HEALTH r-myICES ' . "r-. ,IRONMENTAL HEALTH DIVIS10t, APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT ' PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES RAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS WDICATE PERMIT TYPE ' ❑ REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE jhr $ PROJECT CONTACT"j 1 tS PHONE# (o 6C_z FACILITY NAME SA C Z PHONE - 7j(� ADDRESS Q rj CROSS STREET OWNER OPERATOR \ = PHONE 4(p$- p V CONTRACTOR INFORMATION CONTRACTOR NAME Qi f PHONE ka - $ 3 CONTRACTOR ADDRESS 960, (, _ !S- Lo C CA LIC S 30 Q CLASSf~-(o "j, INSURER d, WORKER COMP# FIRE DISTRICT Z tp PERMIT it 14 I)sk ' LABORATORY NAME f - , COUNTY PHONE Z SAMPLING FI -• L PHONE # 2(] 1 OCo ' TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED L 39- 39- 39- 139- APPLICANT 9- 39- 39-APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS AND RULES AND REGULATIONS OF SAN JOAQUINL COUNTY PUBLIC HEALTH SERVICES OWNER OR LICENSED AGENTS SIGNATURE CER15465 THE FOLLOW[NG '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 CALIFORNII' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING 'I CERTIFY THAT IN THE PERFORMANCE OF THEE WORK FOR V"CH THIS PERWr MIMED.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION!LAWS OF CALIFORNIA.' APPLICANTS SiGiVATv� TITZE fhr&tg3 P(lk okl JtEla _ DA �-2 ' ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) ' PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST SE SUBMI I I TO EHD FOR APPROVAL PRIOR TO CO>EIIRENCING WORK ' CONDITIONS: ' EH 23 048 (REVISED 10119198) Page 3