Laserfiche WebLink
SAN Jn OUIN COUNTY PUBLIC HEALTH,�ERVICES <br />*NVIRONMENTAL HEALTH DIVISJ <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />REMOVAL <br />❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />TANK INFORMATION <br />TANK ID # `" <br />FACILITY INFORMATION <br />INFORMATION <br />EPASITE# ( <br />2008 <br />PROJECTCONTACT AAINIE AG <br />PHONE# 7di-4:? - 37- <br />FACILITY NAME <br />South <br />44:7— <br />PHONE # 205-940- ZZlc4' <br />ADDRESS <br />INSURER State Fund Insurance <br />AI oLT14 wtL-'y�J (,,j , STCC%fL1J <br />S]�,�� <br />CROSS STREET <br />�, n,�� <br />OW+'li <br />PERMIT # <br />OWNER OPERATOR <br />ArJN <br />E- Pot,,G <br />PHONE # 2d9 - q3M-4S3Z- <br />TANK INFORMATION <br />TANK ID # `" <br />CONTRACTOR <br />INFORMATION <br />CONTRACTOR NAME SEMCD <br />39-� ; Z p <br />Sop C -040r\ <br />PHONE* 209-524-9653 <br />CONTRACTOR ADDRESS 1217 <br />South <br />7th Street <br />CA LIC # 449864 <br />c LAssc6l <br />INSURER State Fund Insurance <br />Company <br />WORKERCOMP# 007108-98 <br />FIRE DISTRICT <br />P <br />PERMIT # <br />LABORATORY NAME GeOAnal <br />tical <br />COUNTY Stanislausl PHONE #S72-ogno <br />SAMPLING FIRM GeoAnal <br />tical <br />PHONE x 209 572-0900 <br />TANK INFORMATION <br />TANK ID # `" <br />TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />39- � I C)( <br />C -AL -Dl J (-lN)kwwr.J I' -201 Rkx�u�'f- Uoi:::I� <br />39-� ; Z p <br />Sop C -040r\ <br />39- <br />39- <br />39- <br />39 - <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING'. 'I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br />TO BECOME SUBJECT TO WORK COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: 'I CERTIFY ATI THE P RFORMANCE o E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECTTO <br />WORKER'S COMPENSATION WS F.P.gIAORWA- : / <br />APPLICANTS <br />TITLE �717�r - DATE 7 �Z <br />❑ APPROVED YAPPROVED WITH CONDITION(S) <br />Cl DISAPPROVED <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME <br />DATE (3 <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />n /Aia;�,,. .4vAE. have ; CkJ",4V- x* <br />_I(I",a-f <br />CZ4&4LOA <br />'..�Z c !� <br />P <br />❑n 23 046 IREvibtu lUl19/9B) Page 3 <br />mm <br />