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COUNTY P HEALTH ICE SAN JOAQUIN COU PUBLIC H H SERV S ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTITEMPORARY.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: L9'RAN�EMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE#CATO6007-41 SLI PROJECT CONTACT t CCG -V Z PHONE#70Z-7 6S-1660 FACILITY NAME NPI 'G ( PHONE# 2CPI-331I 00l O ADDRESS IZq W. EI+w sk I.e i L°q CROSS STREET P. CI. rC OWNEROPERATOR ? @I PHONE# 9Z$-an,- CONTRACTOR INFORMATION CONTRACTOR NAME I PHONE# q 4,- SSS `rS 7StiC CONTRACTOR ADDRESS aVt, O-Q CA LIC# CLASS INSURER cL WORKER COMP# FIRE DISTRICT PERMIT# LABORATORY NAME COUNTY PHONE# - I L SAMPLING FIRM PHONE # 612 Li-+S • 2 i G TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED 39- 745 '{ 000 ca.(, Nese I TVA Mvit 39- 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 CALIFORNIA.' APPLICANT'S SIGNATURE TITLE DATE ❑APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/0R ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046(REVISED 08/13/99) Page 3