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nt By: 6UTTF CO ENVIRONMENTALHEALTH; 530 895 6512; Nov-25-02 4:34PM- -11Vlf <br /> sUT400UNTY DEPARTMENT Or PUBLIC&LTH DEC 0 4 2002 <br /> Division of Environmental Health <br /> P.o. Box 5364 (411 Main Street) Chico, CA 95927-5364 ` «©, Calrfamia <br /> U APPLICATION FOR PERMIT FOR TEMPORARY CLOSURE <br /> UNDERGROUND HAZARDOUS MATZRIALS STORAGE TANK (S) <br /> ane of Establishment-: <br /> VP c4 Assessor Parcel erbr <br /> ite Address/Location: J7� MC1rroQ �c I cktco <br /> ling-Address-`o f3O}C 1 RM 3�+o©_Sf+/) l_a-mon , (f,4 <br /> _�}� 3________________ <br /> --_ ------ <br /> rank Owner: PAG! <br /> nk Owner's Address: J?O �PX SZ Sr; �'tYl `LDD 1 fir) ple.rno o , q q-,s5 I <br /> `Cl.ephone: qts� tp I -21d p.licant's Nama: t 11k"1 L�nVIC�o(1rnGrrFu� Telephone: <br /> q 2j�T 2 8 8 zp3 <br /> Cailiag rlddrass. g00_5 'torr a I C a wa �'onC.on, o iq 5F <br /> osure Kethods proposed: Tem�oraftj - 5e_<_ <br /> posedDispositionof----- <br /> - - ------ -------------------------------w__ -__ --- -- <br /> Sure CoAtractor: l�C+tv��Sa�l nv�a o,�mGfi�e Telephone: 70'7 ?q'1 6bgq <br /> Lie. Xbr. 1W100 <br /> ling Address: q 1O 1bvdvsrt'la,1 , xntt: 0. ,Cfl Lic. Type A lfl-3b I14Ak]etc; <br /> re <br /> r$r Co2per1s+s6ori Dec arat on: S hereby affirm gindor penalty of per ttry one of the <br /> )llowinq doc.jarationrar <br /> r have anri rill Maintain a carelfieate of oaxr~t to neat-insane far wortsrs' compeasattca as provided <br /> for by Soctlon 9700 of Eho Labor Deer., for the performanow of Um work for which cblr p.a1r 10 <br /> laarted. <br /> ! I have and will maintain workers, corteosarion insurance, as required by .9scrI04 3700 of the labor <br /> Code, for Cho perfaxnAnc+o or worn for whiaft ChIs petmlt is issued. My workers' comprnsatian insurance <br /> carrier and policy number are: <br /> Carriers.. ",(RTL C.0MP2,v5F}1*ton f.USvl.BnaG[ �imr} policy M a[ wr: -7)3 C7C7CM 3t7q$ <br /> (rhar show s+eCions need not be Completed If Che pera3t 1s for Mork of a valuation of a-no hundred <br /> adollara {,7100) or Jose). <br /> X cerclfy clot la the prrrFotsairy of the wort fpr 061ch Cb1e ponelt is lssuad, S sAall not OV10y any <br /> F,er200 in ani+ RNUUMr an as Co bpon r s©bj*Ct to workers' componsaCloo jars of Ca,iifora3a, and agree <br /> that if r should beccow subject co can workers` Campeasatlos provisions at !Section 3700 of ,the Labor <br /> Cbme, r aball forthnrtta oaroly with Cho" provisions. <br /> GATE -- <br /> 8lgnarura QfVAPPUC^nt <br /> ICHMENTS TO BE INCLUDEDI Closure !fork Plan - Date Recd a - <br /> Site Specific Aealth 4 Safety Plan - Date Recd <br /> closure Fee: <br /> ���ni■■�r.rrr■■r■rr u+ w,i nu i� wa <br /> L_=L� <br /> 'ZiE.DtT USE bVI Recaip�L t�i o. _ Date ��Q - a <br /> it laaued By Exp1p LTION DATE: <br /> teepe owe app e <br /> 11/25/02 MON 16: 18 [TX/RX NO 85971 Z002 <br />