Laserfiche WebLink
�. .oe <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMS <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> x_ REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # M�0015jqjoq I PROJECT CONTACT 8 TELEPHONE # -ri,,(� U( lZm9) S7ff_96r3 <br /> F FACILITY NAMEPHONE # <br /> A <br /> ADDRESS <br /> I 208 <br /> Arm <br /> L CROSS STREET r rm <br /> T OWNER/OPERATOR PHONE # <br /> Y r3i i Peker Czc>S1 fst-oyz- <br /> C CONTRACTOR NAME $IIim PHONE # (209) 524-9653 <br /> 0 <br /> N CONTRACTOR ADDRESS 1217 S. 7th St. Modesto, CA 95351 CA LIC # 449864 CLASS A,B,C61/D40 <br /> T / <br /> R INSURER Insurance Company _ SfA� Poo WORK.COMP.# O/7fj� 7 <br /> A <br /> C F ISTRIC OF .51VfJ" PERMIT # <br /> T <br /> 0 LABORATORY N Geoanal iCal 7 COUNTY Stanislaus PHONE # (209) 5572-0900 <br /> R <br /> SAMPLING FIRM GG- Geoanalytical Lab PHONE 9 (209) 572-0900 <br /> 39-_/_.S4TANK 10 #f /D vtl�ANK�$IuZE CNE„LCLLS �ORE�CUSRENTLY/PREVIOUSLY DATE INSTALLED <br /> T 39- / /D i9 o („JAI. (` C u j <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A / � (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) GATE ����y+/1 <br /> PLAN REVIEWER'S NAME Y <br /> 1))1[fill III I I I I III 11111111111111111111 11 <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 MANNERASTO 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 OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." 4I I <br /> APPLICANT'S SIGNATURE: TITLE IA/I(C W�-�. TITLE "- P(4Y OV' DATE <br /> U <br /> CONDMON(S): Underground Service Alert will be contacted at least 48 hours prior to start <br /> of excavation. <br /> � - Cl= -V;� <br /> EN 23 0" (Re4ed 7/1490`Y' <br />