REMOVAL_2003 - Laserfiche WebLink

Home Browse Search

HUMBOLDT COUNTY UNDBRUND STORAGE TANK PROGRAM APPLICATION FOR PERMIT FOR: Date Paidj Z 0 Z. URTMENT OF HEALTH AND HUMAN SERVICES NVISION OF ENVIRONMENTAL HEALTH(DEH) Repair/modification(includes leak detection&product lines) eceipt#:_� H STREET,SUITE 100 Installa` n JREKA,CA 95501 +v losure ,r-�M O ramount 767)445215 Identify tank(s)involved: tl T.-}Q Application is hereby made to the Humboldt County Health Officer for a permit to construct,repair,or alter an underground storage tank,or for closure, temporary or permanent. This permit application must be signed on all three signature lines by the same person,i-e-,contractor or owner/operator. FILITY NAME:20�A( S ell\ "ACILITYADDRESS: 699 RU/Y)6n0 J QoRD T _ U/STATE/ZIP: r'15`n/ PHONE: Q25 �j(,>> -J4-244c)) S STREET: Y(�y 1� FIRE DISTRICT:--4, r )WNER'S NAME: ipc n F ER-S ADDRESS:—'QO Bt�1. STS F�Im /STATE/ZIP: 583 PHONE: Z -ID O )PERATOR'S NAME: A5 E ERATOR'S ADDRESS: /STATE/ZIP: PHONE: ADEC :ONTRACTOR'S NAME:— �k05.S -Inv l fY rgyl 'f-m NTRACTOR'S ADDRESS:_ ,Oa U�t, (\-f Sart>c, TROMeWAL HEA IYISTATEIZIP:_ 7,vtt,�.t�� CI6501 PHONE: N Q ku MS OF PERMIT -Applicant Agrees That: mboldt County DEH will be notified a minimum of 48 hours prior to starting work. mboldt County DEH inspection will be obtained prior to backfilling andlor covering the work(where applicable). 1)ANY DEVIATION from the approved permit without prior approval from the Humboldt County DEH may be cause for stopping work until the changes are fully justified and approved, his permit is subject to revocation if found to be in nonconformance with Humboldt County Cade,City Codes,or standards of the Humboldt County DEH or State Underground Storage Tank Regulations. [[`� �n I,it 1the undersigned owner/operatorlapplicant of the subject facility,hereby authorize G 111 4(, to release any and all analytical results,geoterhnical data and site assessment information to the Humboldt County DEH as soon as it is available and is provided to me or any representative. dditional items: understood that the issuance of a permit in no way indicates that a guarantee of perfect and indefinite operation is made by the Humboldt County DEH. I hereby acknowledge I have read this application and state that the above information is correct and agree to comply with all County and applicable city ordinances,and state laws regulating rnderground storage tanks. This permit shall expire by limitation if wark authorized is not commenced within 90 days. X-�JA O undersigned applicant certifies the following: SIGN RE OF APPLICANT Yes i5 Coastal Zone Permit Agency contacted,if project is in Coastal Zone. NTRACTORS'LICENSE LAW CERTIFICATE (Complete A or B) WORKERS'COMPENSATION CERTIFICATE (Complete A or 8) Uk The applicant is licensed under the provisions of the A. A currently effective certificate of Workers' Contractors'License Law under License# Fi Compensation Insurance coverage is on rile with the and said license is in full force and effect. Humboldt County 0EH,Policy 38� B.The applicant is exempt from the provisions of the B.I certify that,in the performance of the work for 16y3z9 -Co Contractors'license Law for the following reason: which this permit is issued.I shall not employ any 1)Owner/Operator person in any manner so as to become subject to the 2)Other(explain) Workers'Compensation laws of California. TA�Ml X tAr55 APPLIC T DATE: APPLICANT DATE: tAPPROVED:"6"N WORK- r TE: L {/d 0 WORK APPROVED: DATE: =XPIRATION DATE: �N TRANSFERABLE WHEN APPROVED,THIS IS YOUR PERMIT UST 412002 (Page 1 of 1)