REMOVAL_1991 - Laserfiche WebLink

Home Browse Search

ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: o REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE EPA SITE #G✓y �¢¢f'91p PROJECT CONTACT 8 TELEPHONE L# , -,,V /,/�7 7, y_.y,�o F FACILITY NAME �"s PHONE A C ADDRESS L CROSS STREET i / OWNER/OPERATOR .7 PHONE Y GLI G.IC C CONTRACTOR NAME E/.�l�T CO/YS'T PHONE N CONTRACTOR ADDRESS ��I/J� /'yOTf�'� CA LIC CLASS Q�/O T R INSURERFi(/LCii/J/9� =N�. / WORK.COMP.# A C FIRE DISTRICT /Y//' PERMIT # T 0 LABORATORY NAME / ��✓ PHONE # R SAMPLING FIRM �� PHONE # 111111111IIIIIIII IIII 11111II JS TANK 10 # TANK 512E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- 2553�D1 T 39- A 39- N 39- K 39- 39- 39- P yl L APPROVEDROVE WITH CONDITION(S) DISAPPROVED A /1 ENT WITH CONDITIONS) N PLAN REVIEWERS NAME W ✓ Y T DATE IIIIIIIIIIIIIIIIIIIIII IIIII'I'IIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIII1111IIIIIIIIIIIIIIIIIIIIIIII IIIIII IIIIIIIIIIIIII APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 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: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE. TITLE DATE EH 23 046 (Rev 2/8/91) It Page 3