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VA SAN JOAQUIN COUNTY PUBLIC I IFAI..I t I SFRVICF.S ENVIRONMENT-AL HFAL-TI I DIVISION �hPPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTlTEh1rORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARLtUUS SUBSTANCES STOR �E•TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE' t ❑ REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION Pf PROJEC T CONTAC T EFA SITE# --- - - -��--1L�- �-------- ----- - _ PHUNE#_------------------- _FACILITY NAME � ( �EQ ---- - -- - -----'-- --- ADDRESS 7 Z -- ---------- -- ------ --- CROSS STREET —_ ------------ ----- -- OWNER OPERATOR 4ilJ PHUNE #, - Z- 6 Z CONTRACTOR INFORMATION CONTRACTOR NAME� TO �Qtk�- 1Z`ST �_CIA.(a, ,J ------- --- -i- i CA LIC #_ oQ10 —_I CLAS CONTRACTO ADDRESS 6)0_.7 _,— �..LG� 1.----- - -- pp�� INSURER f/itl 4,& Y IA/� �` L WURKER LUMP# FIRE DISTRICT - .-.-_---r/� /_ PERMIT# �- p BORATORY NAMECOUNTYNE _/T 6 ZASAMPLINGFIRM � PHUNE d TANK INFORMATION TANK ID# TANK SIZE -TANK CONTENTS(PRESENT & PAST UATE INSTALLED ------------ 39- 39- 39- 39- APPLICANT ------39-39 39-APPLICANT MUST PERFORM ALL WORK IN ACCORnA1ICE WITH SAN JOAOUfTJ COUNTY ORDII)ATICES. STATE LAWS. FEDERAL LAWS. AND RULES AND REGULATIONS OF SAN JOAOUIN COUNTY rURLIC IIFALIH SERVICES OWNER OR LICENSEn AGENT S SIGNATURE CERTIFIES TI1E FCI IOWING -I CERTIFY THAT IN THE PERFORMANCE OF TIIE WORK FOR WIIICH THIS rFRMIT IS ISSUED.I SFIAI.L NOT EMrLOY ANY rERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKERS cOMrENSATIUN LAWS OF CALIFORNIA.- CONTRACTOR S HIRING OR SUBCONTRACTING SIGTIATURE CERTIFIES TIIE FOLLOWING 'I CERTIFY THAT IN 11 IF rERrORk1ANCF Or TIIF VJORK FOR WIIICII TIUS rFRD.111 IS ISSIIED.I SIIAI L F%irl n'r rERSONS SUR JF.CT TO WORKER S COMPENSATION LAWS Or CAI IrnntIIA' ArrLICAN T'S SIGNATURE 1111 F ItAIE ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) DATE PLAN REVIEWER'S NAME -___--_-------_----------- -- -- - ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: Fll-23-N4 (REVISFD 08/13/99)