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SAN JOA IN COUNTY PUBLIC HEALTH SE ICES(cfl ti EVRONMENTAL HEALTH DIVISIOI� ' APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT 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: Q REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE TANK INFORMATION FACILITY INFORMATION TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED EPA SITE #G Ci, Z -£`F4 PROJECT CONTACT r jGtiWc PHONE# 7 - FACILITY NAME (:'� L ti . "a i _ PHONE # ADDRESS 3:5 �`�TC r� �•5 Z C CROSS STREET OWNER OPERATOR Pt D�y PHONE # TANK INFORMATION CONTRACTOR INFORMATION TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED �r CONTRACTOR NAME — '_ "' - � CONTRACTOR ADDRESS' f' ^ "r CA LIC # . PH ONE # `)G• ( CLASS G (c� C INSURER IDA 2_-O, 11 � WORKER COMP# _ 6'/6 E= FIRE DISTRIC PERMIT # LABORATORY NAME n GCJ� COUNTYAL,,me �� _ SAMPLING FIRM A Cry��G. �il�_Gv.tic�+�}( PHONE # -O • �•-4(,-7.- l6z)k? TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- L 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE V�ORK FOR WHICH THIS PERMIT IS ISSUED: I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPEN TION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THA THE PERF RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION 1 S 0 CALIFOR IA APPLICANT'S SIGNATURE TITLE r_�AC"— DATE 'G i" f~ ❑ APPROVED EfAPPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAMDATE-L ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS; EH 23 046 (REVISED 10/19/98)