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• SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT PLAN REVIEWER'S NAME O DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE 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( V ��i/4/�= TITLE NQ-,tm C FUER DATE CONDITION(S): - S:��76�k eg,� 144ql�Zv— 6Z-" EH 23 046 (Revised 9/11/96) Page 3 THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE EPA SITE # PROJECT CONTACT & TELEPHONE # k-Ru%/N DAlekeS C'n)S.SB- 760 3 F FACILITY NAME—, S — L � I PHONE 3 5 A ADDRESS z J 5 -�- U L R I L CROSS STREET I T OWNER/OPERATOR P ONE # Y _ \ C PA N S 1 J C CONTRACTOR NAME -- ; _ _ PHONE #(G%i(o/ Z _ - 0 N CONTRACTOR ADDRESS 3SZS Z p E SAcro-ninon A CA LIC # 35SzD CLASS 11Ao4 8 c/U T R INSURER�o��yy� �Cc�t WORK.COMP.# NwG4k, A CFIRE DISTRICT F — _ PERMIT # V rn� I s (10 v1 r�tl T 0 LABORATORY NAME _ COUNTY 51� ti PHONE # R SAMPLING FIRM TANK ID # 39- vGr — PHONE # /A SIZE CHEMICALS TORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED c�No I Lllk�S of ( unknown T 39- A 39- N 39- K 39- 39- 39- P L A N APPROVED APPROVED WITH CONDITION(S) DISAPPROVED SE ^A�; (E CONDITIONS BELOW AND/OR ON ATTACHMENT) , PLAN REVIEWER'S NAME O DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE 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( V ��i/4/�= TITLE NQ-,tm C FUER DATE CONDITION(S): - S:��76�k eg,� 144ql�Zv— 6Z-" EH 23 046 (Revised 9/11/96) Page 3