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ENVIRONMENTAL HEALTH DEPARTMENT APPLICATION F( UNDERGROUND STORAGE TA. ' 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: XREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# PROJECT CONTACT er6 Aukf_ PHONE# FACILITY NAME GLC t I PHONE# Z4�>f- l(5-1 ADDRESS 60 mv' may. G CROSS STREET Md1e'Z Ljon/ OWNER OPERATOR (3 q` Ce,t4 N L PHONE# Zd — I CONTRACTOR INFORMATION CONTRACTOR NAME rl D1,24 rQ tiiL 0.( -7 PHONE# J-16 -(¢( -'93 4d CONTRACTOR ADDRESS l Zj Q CA. CA LIC# CLASS 2- INSURER F-4 WORKER COMP# 1 Z 14 yjD�f FIRE DISTRICT 61 4 PERMIT# LABORATORY NAME -ST-L- COUNTY w. I 4iONE# 52s' SAMPLING FIRM vby ,c+1 PHONE # O - S - D TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST) DATE INSTALLED 39- ( /lf6, 77 �i< c 14 ✓ 0 A I-eke&el c/f foe 11'.iC L 4`d 7 39- l 127 oad P 4 v.3 61 ti (.eAc Gro 39- 2/44re k w. 'r U rrdr �4seli 1 39- k 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 AGENTS 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�/` . /%'�( � TITLE to kV) DATE OC? 67/U�/ ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE 6_11/tv ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. 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 []