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SAN &QUIN COUNTY PUBLIC HEALTRVICES MMENVIRONMENTAL HEALTH DIVIS APPLICATION FOR UNDERGROUND STORAGE TANK 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: • • ❑ REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE # PROJECT CONTACT PHONE 6'? FACILITY NAME D FF&'M.S� IDIS Tc I!3 u Ti v 1V />ElGT s1N QUI PHONE ADDRESS T ffT 11 ' ff 3 0 CROSS STREET --S' CONTRACTOR ADDRESS OWNER OPERATOR PHONE # a09 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- Iq /z,DOd'? aj, pi'--se-k 39- /,), co 0 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 PUBLIC HEALTH SERVICES. 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 THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFOANIA." i, APPLICANT'S SIGNATUREL�c%Ly�o� TITLE Nf DATE_�� ❑ APPROVED 13'APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE_�� ANY DEVIATIONS FROM THIS APPLICATION MUST B UBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. ,CONDITIONS: S.Qk 8 EH 23 046 (REVISED 08/13/99) Page 3 CONTRACTOR INFORMATION CONTRACTOR NAME 6 p F O N ! N'c PHONE # e /01 CONTRACTOR ADDRESS KS— ,4 I T K'9 '1 CA LIC # el31 2 CLASS INSURER WORKER COMP# FIRE DISTRICT hi Iqj /,�c� /VC'// 6� ��9�y Z PERMIT# LABORATORY NAME S c cJ COUNTY _qq(2,CXglL<1V4 PHONE SAMPLING FIRM ALT&.eC14 CnNS , /NG ��. PHONE # /6 f/ -26 p TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- Iq /z,DOd'? aj, pi'--se-k 39- /,), co 0 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 PUBLIC HEALTH SERVICES. 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 THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFOANIA." i, APPLICANT'S SIGNATUREL�c%Ly�o� TITLE Nf DATE_�� ❑ APPROVED 13'APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE_�� ANY DEVIATIONS FROM THIS APPLICATION MUST B UBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. ,CONDITIONS: S.Qk 8 EH 23 046 (REVISED 08/13/99) Page 3