Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW2 <br /> REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE / PROJECT CONTACT & TELEPHONE +1J4,ck _ <br /> F FACILITY NAME 1 (IC.i PHONE 1 <br /> A / <br /> C ADDRESS <br /> 1 <br /> L CROSS STREET <br /> 1 PHONE <br /> Y � COPERATOR / � ' I / n p 3 8(a - oo- <br /> C CONTRACTOR NAME PHONE M Q 3S <br /> 0 CA LIC MCLASS _ ��� <br /> N CONTRACTOR ADDRESS ((�- O <br /> T WORK.COMP.R () <br /> R INSURER �. G r 1 <br /> APERMIT k <br /> C FIRE DISTRICT <br /> T PHONE 0 - d� -- �y , <br /> 0 LABORATORY NAME <br /> R ' n <br /> SAMPLING FIRM c�/i'S�`" PHONE 0�6fl- <br /> IIIIIIIIIIIIIIIIITIIIII III <br /> ' TANK ID �7 SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE ST INSTALLED <br /> 6ia'SO <br /> 39- //iT r <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> r39- rrtmrmrrrlirrtt>�Imtmnr nmmrrrrirrm rmnrrrrrrrmirrrr <br /> P <br /> L APPROVED APPROVED WITH CONDITION(5) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) TiTTT�7TTYTY7�-7FY7�DATE <br /> N PLAN REVIEWERS NAME IIIIFIFFFFF�IIIIIIIIIIF""1"„"""'11111 <br /> 11111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> TSAN JOAUIN COUNTY HE PERFORMANCE OF THE PUBLIC <br /> IWORKE FOR HWHICH I THIS PERMIT IS <br /> ISSUED, IASHALL SNOT GEMPL Y ANY NATURE T PERSON IFIES T IN SUCHHE aAI MANNER I ASETOI FY T IN <br /> LICENSED BECOME <br /> TING <br /> SIBLERTIFYY WORKER'S <br /> IN THEMPERFORMANCEAWS OF THE WORK�FORAW41CH�THISCPERMITH ISNG OR ISSUED, ICSHALLCEMPLOYSIGNATURE <br /> PERSONS SUBJECTCERTIFIES <br /> TOTHE <br /> WORKER'�ING: <br /> COMPENSATION LAWS OF CALIFORNIA.• <br /> APPLICANT'S SIGNATURE: -'/ TITLE #LdP�� DATE <br /> T.es� o-vile a�c� ���'�o,�c. ��� �,•a.� za � � 7�-� <br /> EH 23 046 (Revised 7/10;/92) Pelle 3 <br />