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SAN Jq#UIN COUNTY PUBLIC HEALTH WVICES VIRONMENTAL HEALTH DIVISIdW APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTI TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE. EMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPASITEAtCO9b PROJECT CONTACT` PHONE# FACILITY NAME UIL.0 I PHONE;*4f ADDRESS l p CROSS STREET OWNER OPERATORPHONE# bi CONTRACTOR INFORMATION CONTRACTOR NAME hd E6PHONE# CONTRACTOR ADORES ��. LIC# I CLASS 0/eof INSURER (, WORKER COMP# : P277/ FIRE DISTRICT PERMIT# HA-1 LABORATORY NAME 6zV Oi A A- 1 COUNTY PHONE# 2 ZZ SAMPLING FIRM t,( I PHONE TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED 39- I E. 6bo N L i tvE ' N 39 I j 39- - `' S W Uk-tip 139- 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: '1 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: '1 CERTIFY THAT IN THE PERFORMACE.OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS)PF CALIFORNIA.' —1A L'uM p APPLICANT'S SIGNATURE TITLE TITLE ' J N�C�IDATE ❑ APPROVED APPROVED WITH CONornON(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM IS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: e E>14 3 046(REVISED 10/ 9/98) P Pape a d