Laserfiche WebLink
SAN JO,, -,..JUIN COUNTY PUBLIC HEALTH SL 'ICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSQRE PERMIT <br />THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES W DAYS FROM THE APPROVAL DAi E. DO NOT WRITE IN ANY SbiACED AREAS. INDICATE PERMIT TYPE: <br />3 -REMOVAL Q TEMPORARY CLOSURE Cl CLOSURE IN PLACE <br />TANK INFORMATION <br />APPLICANT <br />FACILITY INFORMATION <br />:CNTR.ACTOR NAME <br />PA_ SIDE =_i- O �- <br />L�40JECS._CvNTriCT _ Ll���t.!—_J����J—_ <br />. �HCNEs—� 3—O- - 57`� <br />ZACILITY NAME '-" <br />- <br />=HONE * 3 - 3 moi- t 6 <br />A D C R E 3 S % <br />7 L t 20 <br />k LAQ I COUNTY PHONE <br />:ROSS STREET `2 A <br />i PHONE ; I <br />OWNER OPERATOR <br />r J A <br />?HONE 4 333 -3`+- 1 Co <br />TANK INFORMATION <br />APPLICANT <br />CONTRACTOR INFORMATION <br />:CNTR.ACTOR NAME <br />Z,13a ! PHONE G - iib- VT 7 <br />CONTRACTOR ACORESS <br />p t1 'Ani C' LA CA LIC T -,S 3 I CLASS 4 <br />INSURER �- ,. <br />I WCRKER COMP# Q <br />FIRE DISTRICT <br />! PERMIT 4 <br />'LABORATORY NAME �_o AJAA <br />k LAQ I COUNTY PHONE <br />SAMPLING FIRM I I <br />i PHONE ; I <br />TANK INFORMATION <br />APPLICANT <br />TANK IDT <br />f TANK SIZE I TANK CONTENTS (PRESENT 3 PAS i I DA 1= INSTALLED <br />39- 'I �- <br />I ) � � <br />� ;yli � � <br />C ' <br />i 39- <br />-30-j39-39- <br />39- <br />139- <br />39- <br />APP!ICANT MUST PERFORM ALL'NORK IN ACCOROANCZ WTH SAN JOAQUIN COUNTY ORDINANCES, SIA, c LAWS. FEDERAL LAWS. AND RULES AND <br />REGULATIONS OF SAN XAQUIN COUNTY PVBUC HEALTH SERVICES. OWNER OR UCENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: '1 <br />CERTIFY THAT IN TIRE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT :S ISSUED. I SHALLl4OT EMPLOY ANY PERSON IN SUCH A MANNER AS <br />TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE Cc.RTIFIES <br />THE FOLLOWING: 'I CERTIFY TIIAT IN THE PERFORMANCE OFT HE WORK FOR WHICH THIS PERMff IS ISSUED. 1 SHALL EMPLOY PERSONS SUBJECT-] O <br />NORKER'S COMPENSATION LA OFyCAU NIA' <br />APPLICANTS SIGNATU ( ' TiTt�tKJ I DATE <br />G APPROVED FZAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />/1 1 (SEE CONDITIONS BELOW ANOlOR ON ATTACHMENT) <br />l <br />_z/ <br />i <br />PLAN REVIEWER'S NAME� '/'r� DATE <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHO FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />r':1i°r•,/�. -'f),•ii' _�(I�I :I" LCCC l�'-��/�7/ , '".'��iY !,J/I .•f %'✓! ����C ^, f <br />cH -73 0,16 ,,REVISED 'C/19198) ?3Ge 3 <br />--foL" <br />