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SAN JWUINCOUNTY ENVIRONMENTAL APPLICATION FOR STORAGE CLOSURE 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: ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE #[A 460213' PROJECT CONTACT PHONE# o -&14 - 3 YO FACILITY NAME - 0 0 PHONE # ' ADDRESS �ROAP CROSS STREET SECKel4AI ROAQ OWNER OPERATOR SrAr 10PHONE # TANK INFORMATION CONTRACTOR INFORMATION TANK SIZE TANK CONTENTS PRESENT & PAST DATE INSTALLED 39-!� CONTRACTOR NAME 39- PHONE # Y10 39- CONTRACTOR ADDRESS 2600 W14.1-1AIqS 0 1 CA LIC # C077902 cLAssAi3c8clo 39- INSURER t ® JAJ5VrAALCE CO. WORKER COMP# - C61 FIRE DISTRICT 40,01 PERMIT # LABORATORY NAME SELIV9JA COUNTY PHONE # 0 ZZ SAMPLING FIRM PHONE # /C1 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT & PAST DATE INSTALLED 39-!� 1 WAST'- 014. #, q 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: "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: "I CERTIFY THAT IN THE PERFORMANCE OFTH R WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." O% ❑ APPROVED IYAPPROVED WITH CONDITION(S) (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME LldJ J�� DATE' ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: ® EH 23 046 (REVISED 08/13/99)