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ENVIRONMENTAL HEALTH DEPARRjE[ SAN JOAQUIN COUNTY MAR 0 2 2016 APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT ENVIRONMENTAL H.FA!TU 171170�L-T�AGAlT THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE c� FACILITY INFORMATION EPA SITE j PROJECT CONTACT 1W1%,le7 // ) PHONE#7y� jL� jJ FACILITY NAME JZ1 PHONE# ADDRESS r� Q /: c1%/y�/�/�/✓v�cc' 1jLl�l�. CROSS STREET ' ]' /_ OWNER OPERATOR �,- LL PHONE# D L CONTRACTOR INFORMATION CONTRACTOR NAME /`/�+d/Z/ ©/e /t)e-. I PHONE# 2_e! 25 S;�T-I CONTRACTOR ADDRESS �d O C �l�f CA LIC# �v C CLASS/I/3 /� Z INSURER WORKER COMP# FIRE DISTRICT C'/ PERMIT# LABORATORY NAME G>+�� ` COUNTYT� PHONE# SAMPLING FIRM l C1,04 L PHONE# 2-&—S �—Ci i4 4z;/ Z- TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLE 39- 39- ' -F 7A 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 ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR 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 TH THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WO KE 'S COM IO W OF CALIFORNIA" APPLICANTS SIGNATURE / TITLE DATE [] APPROVED YAPPkovFn WITH CONDITION(S) --! DISAPPROVED EE ON TIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS A ATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITION S�e EH 23 046 (Revised 12/10/2015) 3