Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE 9 PROJECT CONTACT & TELEPHONE A <br /> F FACILITY NAME �' �C'Q ,� I <��� i PHONE \� % <br /> C ADDRESS 1 1.,T 1 1W��ly 00 ��T� u <br /> L CROSS STREET li'1lIJ � Tl'OI`p Y <br /> 1 ' <br /> T OWNER/CPEAATOR I PHONE Y — <br /> XA 3 <br /> C CONTRACTOR NAME IE-L (�s-p 1�, ` PRONE w! <br /> A-0 , b5�3 6 <br /> H CONTRACTOR ADDRESS oba ou CA LIC X CLASS <br /> R INSURER WORK.CCMP.Y <br /> A <br /> C FIRE DISTRICT —r?,A-<,\l PERMIT <br /> T , <br /> 0 LABORATORY NAMEc COUNTY PHCNE 3 <br /> 6 <br /> R a� <br /> SAMPLING FIRMt -l(,b'Lr„ �� SlM1,l. C � PHONE <br /> IIIIIIIIIIIIIIIIIII 111111 11 <br /> TANK ID 3 TA MK SIZE, CHEMICALS STORED NRRENTLY/PREM CUSLY GATE UST 1NSiALLEO <br /> 39• 4A%Vdr1.6W/� ES�� 5(SD Cf/i{,, EtAadi_IwfE d1ER50T S. <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- MMIMMMI1111 11111111 1111111111 <br /> 1111 111 111 1 III II IIIIIIIIIIIIIIIII <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAME DATE <br /> I I I I I i l l l l l l I I I I I I I I I I I I I I1111111111111111111111111111111111111111111111111111111111111111111111111111111 l l l l l l l l l l l l l l l l i l l l <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 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: _d�/�— /Il�.��- _ _ TITLE �BlSi,r9�•s-< .4�r/.v/..yi DATE H - <br /> CONDITION(S): <br /> RUSH <br /> A <br /> E4 23 046 (Revised 7/10/96) Page 3 <br />