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SAN J*UIN COUNTY <br />ENVIRONMENTAL • DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE. <br />PROJECT <br />my <br />( FACILITY NAME 5A1�j v()NcI� Iry G0 y �R1 I PHONE 1� �A r� 4 — ?Y)14 <br />CROSS STREET Lk\ \ j,,,, 5U VOWNER OPERATOR S�J A(J \1\� CQUN�y PHONE#tri ,4\ 4(,B- ��0(o <br />CONTRACTOR NAME y <br />CONTRACTOR INFORMATION <br />�J�Ct '- U E E U [, PHONE 20� - g 33 <br />CONTRACTOR ADDRESS <br />G 5,-TorC CA LIC #30 (� S CLASS[ -( <br />INSURER A L� - d <br />t WORKER COMP# 0 <br />FIRE DISTRICT Z <br />—Lv g PERMIT# <br />LABORATORY NAME <br />- COUNTY PHONE 2 rj 1 <br />SAMPLING FIR <br />- , t - PHONE # 2p (Al - 06 <br />TANK INFORMATION <br />TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />39- <br />39— \ r \ <br />39- <br />39- <br />39- <br />39— <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I <br />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 <br />TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: *1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.- <br />APPLICANTS SIGNATUREf/I �® TITLE �J::,gLf"j R 11k DATE 12 2Z <br />OAPPROVED 11 DISAPPROVED <br />(SEE CONDITIONS BELOW ANWOR ON ATTACHMENT) <br />to <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS—:. <br />L ` ��LL 1 .;Jt -/� ,f:,. , �lil ail <br />Page <br />�l <br />