Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PUCE 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 BELOW: <br /> X REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE If 11 ®Q +`�I.5(e$ - PROJECT CONTACT 8 TELEPHONE # '-T �4S G3 <br /> F FACILITY NAME 1• PNONE # <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> C CONTRACTOR NAME Fs 1 PHONE # _ �5— <br /> 0 <br /> N CONTRACTOR ADDRESS �-IA.. CA LIC # CLASS L <br /> T <br /> R INSURER WORK.COMP.9jf 1 k 0 _00 <br /> FIRE DISTRICT PERMIT Al <br /> 0 LABORATORY NAME PHONE # — Z <br /> R <br /> SAMPLING FIRM v\ Il PHONE # It II 1( <br /> TANK ID # TANK SIZE CHEMICALS STORED WRRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 3 -b l <br /> T 39- <br /> A 39- <br /> H 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 Tff <br /> P <br /> L _ V APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) -1 <br /> N PLAN REVIEWERS NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." _ <br /> APPLICANT'S SIGNATURE: � TITLE C� I J-&T'/ DATE <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />