REMOVAL_2000 - Laserfiche WebLink

Home Browse Search

SAN JOmQUIN COUNTY PUBLIC HEALTH SuAVICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: qREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE # ZRI-OA-700-76241 PROJECT CONTACT u i FPHONE# j 2 S FACILITY NAME PHONE # ADDRESS tlLl L RA CROSS STREET - ' OWNER OPERATOR PHONE # - 8IJ Q D CONTRACTOR INFORMATION CONTRACTOR NAME SEM00 PHONE # 209-524-9653 CONTRACTOR ADDRESS 1 17 South 7th Street I CA LIC # 449864 1 CLASSC61 INSURER State Fund Insurance Company WORKER COMP# 007108-98 FIRE DISTRICT PERMIT # LABORATORY NAME 7AC. 7-W1,—J1.✓6 La 80 Q Y SAMPLING FIRM AL Ti i<tCOCQ?QA " COUNTY f4O PHONE # Z PHONE # 209 572-0900 77' k'10 A APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I 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 TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMACE THE WORK FOR WHICH THIS PERMIT IS ISSUED. 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OORNIA.' 1 A_ L /1' Inn h/C./"1 APPLICANTS TITLE ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME - DATEV //; ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. C NDITIONS: TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- 3 o4(j-oZ t100 n1 — •J I 39- 39- 39- 39- 39 - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I 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 TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMACE THE WORK FOR WHICH THIS PERMIT IS ISSUED. 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OORNIA.' 1 A_ L /1' Inn h/C./"1 APPLICANTS TITLE ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME - DATEV //; ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. C NDITIONS: y rl EH 23 046 (REVISED 10/19198) Page 3