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n 11 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTIfEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAG7TAF (S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERM17 TYPE: MOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE G-4�� ?oZ/ PROJECT CONTACT %'ft�G P e 3� PHONE# C� �% -X3S'oe FACILITY NAME L J✓'L.0 PHONE# Z ADDRESS o w CROSS STREET c% OWNER OPERATOR /) J PHONE /oz - 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; "I CERTIFY THAT IN THE PERFORMANC TH WORK FOR WHICH THIS PERMIT IS ISSUcD, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' APPLICANTS SIGNATURE TITLE PL'CRJ%/!-)CP��/Tod DATES y`' ❑ APPROVED ❑ APPROVED WITH CONDITION(S) (SEECONDITIONS BELOW AND/OR ON ATTACHMENT) �% PLAN REVIEWER'S NAME 1./ `"" `` CONTRACTOR INFORMATION CONTRACTORNAME 50 PHONE %v1 G!I 3 G7 CONTRACTOR ADDRESS 600 fl.G/R/1S . --5R,A) 41'R"pzo I CA LIC # 4 Z CLASS C&!2-0 INSURER L£)i i )r G' WORKERCOMP# "'O" -�l c61 y FIRE DISTRICT 4O LABORATORY NAME - '% (i DiAl- PERMIT # COUNTY s /!J Jh/9T�c PHONE # SAMPLING FIRM A/ / PHONE # CJ o - O 00 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; "I CERTIFY THAT IN THE PERFORMANC TH WORK FOR WHICH THIS PERMIT IS ISSUcD, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' APPLICANTS SIGNATURE TITLE PL'CRJ%/!-)CP��/Tod DATES y`' ❑ APPROVED ❑ APPROVED WITH CONDITION(S) (SEECONDITIONS BELOW AND/OR ON ATTACHMENT) �% PLAN REVIEWER'S NAME 1./ `"" `` ISAPPROVED DAT 10'x/1`7 TANK INFORMATION 39- TANK ID l# TANK SIZE LoS*3 goLo-* 00 TANK CONTENTS (PRESENT B PAST) DATE INSTALLED wjGC,f0r-0 % S *7 39- 39- EH 23 046 (REVISED 08/13/99) Page 3 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; "I CERTIFY THAT IN THE PERFORMANC TH WORK FOR WHICH THIS PERMIT IS ISSUcD, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' APPLICANTS SIGNATURE TITLE PL'CRJ%/!-)CP��/Tod DATES y`' ❑ APPROVED ❑ APPROVED WITH CONDITION(S) (SEECONDITIONS BELOW AND/OR ON ATTACHMENT) �% PLAN REVIEWER'S NAME 1./ `"" `` ISAPPROVED DAT 10'x/1`7 ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. �1';. CONDITIQNS: /1, --- r EH 23 046 (REVISED 08/13/99) Page 3 -- -,r- I :Inn -I4 N 14T 4 EEbE89060Z 10:60 0002 /L L /S0