Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> IXREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT SFF PHONE#�I Y9'g 3 3'°/99 I^ <br /> FACILITYNAME ( PO7f-aMASSle iND4�r' IAt 'PAkac PHONE# NIA <br /> AODRESS 3G2 q S" Ai0 T-W' S N` 9G zz6 <br /> CROSS STREET 2 ( S <br /> OWNEROPERATOR I - 4WD, . O. PHONE# yIb-923-+(ono <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME SPEELA4 E A-R."G N PHONE# a e�- _96"_96"_ <br /> CONTRACTOR ADDRESS 1 S 10 Cxu'NE W CA LIC# 3�1 � CLASS <br /> INSURER ON FIL.0 WORKER COMP# EkBMY; <br /> FIRE DISTRICT C O SIV cp-mv PERMIT# <br /> LABORATORYNAME AtGori i.AU:9/+Ta'Fit5:-s COUNTY STAFN1SLAti1 I PHONE#LO --S-�bI--9'18U <br /> SAMPLING FIRM Cl`, 00 - Ii✓c:9l Ci PHONE # 20q-33'x-HSTf=, <br /> TANK INFORMATION <br /> TANK IO# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- 560 (. UAJ K-NC L.fJ l' AI <br /> 39- <br /> 39- <br /> 39- <br /> 39 <br /> 39- <br /> I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I$ISSUED,I SHALL NOT 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 CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIF RNIA.' C <br /> APPLICANT'S SIGNATUR TITLE # DATE <br /> ❑ APPROVED UAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITI N BELOW AND/CR ON ATTACHMENT) <br /> ` �S Q <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHO FOR APPROVAL PRIOR TO COMMENCIN WORK. <br /> t <br /> EH 23 046(REVISED 08/13199) Page 3 " <br /> 1 <br />