Laserfiche WebLink
SAN JOIN COUNTY PUBLIC HEALTH SEWICES <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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> .X REMOVAL(p jm�t onty) ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> `1 FACILITY INFORMATION <br /> !ADDRESS <br /> PA SITE# PROJECT CONTACT PHONE# - .�. <br /> ACILITY NAME { PHONE# <br /> CROSS STREET <br /> OWNER OPERATOR PHONE# r - <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAMEC P 1 PHONE# < <br /> CONTRACTOR ADDRESS ( CA LIC* ?,qL�EL. CLASS -4 <br /> INSURER I WORKER COMP# <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME Nbp L1 < COUNTY C, <br /> '& # <br /> SAMPLING FIRM PHONE <br /> 1 n � <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39-525 -c e <br /> 39- <br /> 39 <br /> 39- <br /> 39 <br /> 39- I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. SATE LAWS. FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR 'dCENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <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 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br /> � -- <br /> APPLICANTS SIGNATURE � TITLE �fr)IP� �YlLlifl PFS DATE_�;J-"LL_ <br /> ❑ APPROVED APPROVED WITH CONDITIONS) Cl DISAPPROVED I <br /> (SEE CONDITIONS BELOW AND10R ON ATTACHMENT) ..�••�� � ((��qq <br /> PLAN REVIEWER'S NAME IM.• �,��\ DATES <br /> ANY DEVIATIONS FROM THIS APPLJCATION MUST BE SUBMITTED TO E:(D FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> I) Mo LS7- <br /> MCST <br /> $h -RI — ou <br /> EH 23 046(REVISED 10119198) Page 3 <br />