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ftri <br /> BUTTE LINTY DEPARTMENT Or PUBLIC i LTH DEC 0 4 2002 4 <br /> Div'ision Of Environmental Health <br /> P.O. Box 5364 (411 Main Street) Chico, CA 95927-5364r%61CO, California <br /> APPLICATION FOR PERMIT FOR TEMPORARY CLOSURE <br /> UNDERGROUND HAZARDOUS MATERIALS STORAGE TANK (S) <br /> ame of Establishment: <br /> PflelGlGgf-u Assessor Parcel Crow <br /> Site Address/Location: 3720 fr)0rr0Q La.I)G , Ch)co <br /> ailing Addreas s ?j QOK 5V6.1 2 '1 3�ooD 5>q00-mor) , Gan - ------------------------------------ <br /> rank Owner: <br /> ink Owner's Address: T10 Lox S; Pun 39-CaDj SAW) plc-moo , Ca °j4!553 <br /> 'elephone: '125- 90 t ?W <br /> plicant's Name: 51qAW iewip,000c-(VTaVJAC Telephone: 252$8 21v3 <br /> [ailing Address: g005 POCT aicacio d)q vOuv) [ Concon-D CR gg5FS3 <br /> osurs Methods Proposed: TeMpofarLI - SGC ScoPS oFwo2k <br /> roposed Disposition of Tank(a) : <br /> ---------------------------------------------------------------------------------- <br /> osure Contractor: �Jn,vusal n��a•onrnc-of�,1 Telephone. 70"7 '71j') 66R9 <br /> cilia Address: [ol LNdvstc%a.l n � Lic. TypNbr73a�oo <br /> g H In)n� , k7Gn1CIQ. Cf) Lic, Type A 1n3Rj 14p2/1}sL <br /> !kers' Caspensat on Dec araC on: I hereby all rr <br /> m under penalty of peury one of the <br /> )lloving declaretionar <br /> 1 I haw and w1ll aalntals a care ifinate of oonoaae w N1!-lalaua for porters' m)pansatloo ss prnvlded <br /> for by Soceloo 3700 of raw Labor axle, for ehe pstlotmanw at the work for whlcb wilts pair is <br /> Issued. <br /> ,) i haw and rill salhtald Workers' 00" 8AriOA lasuraoas, as rrpulrad by seccion 3700 of the Labor <br /> coda, for Cha perfoneance of work for Weiss this psalt is issued. My wcrteri' compensaeloo Insurance <br /> urtler and polity pasha! are: �• <br /> Carrlsrr_ . ` 1I ComP�..�SAt,o� f.US�r p,yc.L C"CO P-11ey mmbere 713 ocx93y4$ <br /> (the above seetloss need sot be Completed 1f the peale is for wvck of a valuation of one hundred <br /> dollars (8100) or lass). <br /> I wrtlfy chat is the psrl,oehee of the wort for wblcb rills peak Is Issued, X stall noc employ any <br /> perste 1n any manner so as co beano subject to Worters' cmpeesseloo laws or Callfor0la, and Apr" <br /> that if i should becww subject ce the Workers' oaepeaseeloa prvvisloas of sactloa 3700 of the Labor <br /> code, z sb411 lortawlth dosply with chose provlsioas. <br /> DATE ) aZ <br /> algnaturs o Meant <br /> kCHMNTS TO BE INCLUDED] Closure Work Plan - Date Recd <br /> Site Specific Health 4 Safety Plan - Date Recd IQ - 0 a <br /> _. rT £SEs• Closure Too:RT24FNT USE OMT-y-, <br /> Receipt o. o Date 1,0 — <br /> Mit Issued 1�^.S-O� By �• �\ 1ZTXRATION DATE` <br /> teepc ase app c <br /> 11/25/02 MON 16: 18 [TX/RX NO 85971 Q002 <br />