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ENVIRONMENTAL, HEALTH DEPARTMENT <br /> SAN JOAQUIN COU NrrY e ,' <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANKS)EXPIRES IaO DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE <br /> ❑ REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> c-tt J� 00 C 12- S FACILITY INFORMATION <br /> LPA SITE z - --lr I PROJECT CONTACT �- e`_ A 0. C-h T I 0 PHONE# 32- - e 3 F <br /> FACILITY NAME B P r C-0 fG O 2-0 PNONE a <br /> ADDRESS T ` m e, .S 3 3 <br /> CROSS STREET U W <br /> OWNER OPERATOR Z e• f p S( « PHONE# L- - � Tj <br /> CONTRACTOR INFORMATION S( <br /> CONTRACTOR NAME (01--c So fTA z-C-`-^G-At c4.` _ ")'C• PHONE 9 IV I i,` A HA2 <br /> CONTRACTOR ADDRESS Zra GLj W C>-MS s �Ci..teC�.�d/ CA I_!C# 10 u CLASS Jj C- C -1C) <br /> NSURERKIK -,A1 'k e-K . rktj'~ � -Zi8--O WORKER COMPO 1 � (0 s CD C (a I�d 2-3 <br /> TIRE DISTRICT rNICL rt e-cr' PERMIT# N <br /> LABORATORY NAME (e f t COUNTY PHONE# .�- — Z2. <br /> SAMPLING F;RM (-.7-r Ev,vr o.%—eA• tt0. PHONE# <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PA-37I DA TT;NSTALLED <br /> 39- 'c 2c:=*1C) A rnx . <br /> 39- <br /> 39-____- <br /> 9-39-__._ L 660 I+ r r _0 o c], tcc'x <br /> 39- <br /> 39- <br /> 39- <br /> ►.PPLICAN'r MUST PERFORM ALL WORK'.N ACCORDANCE WITH SAN.}OAQU'N COUNTY CIRDINANCES.STA'= LAWS,FEDERAL LAWS, AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING 'I CERTIFY THAT A THE PERFORMANCE OF THE WORK FOR YrHICH THIS PERMIT 15'•SSUED,I SHALL NOT EMPtCY ANY PERSON IN SUCH <br /> MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKERI'S'COMPENSATION LAWS OF CALIFORNIA' <br /> pia- ► r�0"�0` �C DATE T - Z-O <br /> APPLICANT'S SIGNATURE �._-. __- ,-. _TITLE <br /> ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW ANDtCR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME 'AT-- <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> Eli 23 046 {Revised 12/31/071 z <br />