Laserfiche WebLink
�,, fir• <br /> 1 ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE #`,A PROJECT CONTACT 6 TELEPHONE # <br /> K/,/. � <br /> IU <br /> F FACILITY NAMEI ,T D - 0 ak PHONE #�O7��G y <br /> A . <br /> C ADDRESS <br /> I 7#,34 i URG ST <br /> L CROSS STREET <br /> T OWNER/OPERATOR PHONE # <br /> A 17 6 /, 3,2 8 8 <br /> C CONTRACTOR NAME �� T o PHONE # 21 <br /> •� _ p, //�.7/ <br /> 0 J // <br /> tos r7A/bFLFs CA' S�aoo� <br /> N CONTRACTOR ADDRESS CA LIC <br /> OX # �I CLASS A/ µ <br /> T !� 2007Wtx� g T /Y <br /> R INSURERWORK.COMP-# <br /> A ' <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 LABORATORY NAME QTK,fI� ',� PHONE # <br /> R SAMPLING FIRM • �n��� (R_. Vi/<'3 <br /> IIIIIIIIIIIIilllllilllllllllll y PHONE # �/J 5`6 a-8 s <br /> TANK 10 # TANK SI2E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39-rA( B06_57,97 392 60 6 # - 1- 3 - G <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 111111111111111111111111111111 rp <br /> P <br /> L PPROVED WITH CONDITIONS) DISAPPROVED ///111'''q ^ T4 ITN CONDITIONS) -,{ <br /> N PLAN REVIEWERS NAME /1� DATE -/ _ VVV <br /> IIIIIIIIIIIIIIIIillllllll I IIIIIII111111 11101111011111111111111111111111111111111111111111111 IIIIIIII IIIIIII11111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN 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 WINNER AS TO BECOME <br /> SUBJECT TO UORKER'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 <br /> //. .c�K� 4Iu2d^'>-11 DATE <br /> EH 23 046 (Rev 2/8/91) ft Page 3 <br />