Laserfiche WebLink
SAN AQUIN COUNTY PUBLIC HEALTI 7ERVICES <br /> ENVIRONMENTAL HEALTH DIVI816N <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# DVDD� D PROJECT CONTACT IR. ROY FOWLER K209) 948 4036 <br /> FACILITY NAME PHONE# SAME AS ABOVE <br /> ADDRESS 405 N 59 <br /> CROSS STREET F EMONT STREET <br /> OWNER OPERATOR MR. ROY FOWLER PHONE# r <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME , Ar.jFq, .I HQRI I 17P71PHONE#C209 43 <br /> CONTRACTOR ADDRESS Roy — i r/ - 17 CALIC#365234 CLASSA HAZ <br /> INSURER WORKERCOMPS <br /> FIRE DISTRICT PERMIT# <br /> ORY NAM - COUNTY PHONE# <br /> Ke <br /> AMPU17G FIRM � +JFELpFg PHONE # �m8 134 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- 61 IIP ,000 (???) REPORTED GASOLINE ' <br /> 39- - ` 1,000 ??? P.EPORTED DIESEL REPORTED EARLY 1950'S <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE HATH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: -1 <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 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: 'I CERTIFY THAT IN TH FOR E OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS F ;RNLA.' <br /> APPLICANTS SIGNATURE ` TITLE ✓ DATE <br /> ❑ APPROVED Cl APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SE <br /> E CONDITIONS BELOW AND/OR ON ATTACHMENT) 2 <br /> PLAN REVIEWER'S NAMEXIL""(/ /V DATE/ Lq* <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS:_- S 11L . <br /> EH 23 046(REVISED 10119198) Page 3 <br />