Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL /D/ATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />V REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br />CONDITION(S): <br />O �o�z�f9a <br />EN 23 046 (Revised 9/11/96) Page 3 <br />EPA SITE # CAgg71S2 83,q <br />PROJECT CONTACT 3 TELEPHONE #MAuRICe UENSOl1/ avv)99.z-2o76 <br />F <br />FACILITY NAME IDL- A. vEFC,J5C 0,5n 0f -POI SAQJOAOUuJ iKACY PHONE # (ao9)98z- �2v78 <br />A <br />C <br />c _ <br />ADDRESS a57p L)0 S. CNR/5MAA1 RD. TRACY CA 45376 <br />I <br />L <br />CROSS STREET �f <br />I <br />T <br />OWNER/OPERATOR �S, �joyt <br />PHONE # /2U 9) 98z_aJ7B <br />Y <br />Il <br />C <br />CONTRACTOR NAME CALr.JC <br />PHONE # (70 7 yqb _ M& <br />°?ONO <br />N <br />CONTRACTOR ADDRESS PfaaOOY RO' v -y« <br />CA LIC if (,5-77-T4/ <br />CLASSA 8 A58 iIAz <br />VACAVIL4,8 CA 45'4,87 <br />T_ <br />R <br />INSURER SGRE�SI�%_/E /LL ALLC/iL <br />WORK-COMP.#NL,/C[�rYmOS6'OZ <br />A <br />C <br />P' <br />FIRE DISTRICT (. 1 ( a 7 - j'f Cl Z <br />PERMIT # <br />T <br />0 <br />LABORATORY NAME <br />i <br />COUNTY GI �L <br />PHONE # <br />R <br />SAMPLING FIRM��,/�y. PHONE # <br />TANK ID # TANK SIZE CHEMICALS STORED�RRENTLY/PREVIOUSLT DATE UST INSTALLED <br />39- <br />T <br />39- 21 5f ii <br />' <br />A <br />39- <br />— <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />L <br />APPROVED,. APPROVED WITH CONDITION(S) DISAPPROVED <br />A <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN RE. 'EWER'S NAME — �. �h �� DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE F THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />yy �, <br />C`��C— 4AJAG(5& �/2 9g <br />APPLICANT'S <br />SIGNATURE: TITLE DATE <br />CONDITION(S): <br />O �o�z�f9a <br />EN 23 046 (Revised 9/11/96) Page 3 <br />