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. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # LOO13-) ^ PROJECT CONTACT & TELEPHONE # S,�aue ES 707 --199 <br /> F FACILITY NAMEo r. �✓ � PPHONE # Z� <br /> A �II c' <br /> ADDRESS <br /> I ay W T CMI < Avg giJ 33 <br /> 1 <br /> L CROSS STREET S, Aid oCT Wa <br /> I <br /> T OWNER/OPERATOR I PHONE # <br /> C CONTRACTOR NAMEC, PHONE # X0-1 _ yy(p_-199(0 <br /> 0 <br /> N CONTRACTOR ADDRESS ZnqO '7Q1 CA LIC # CLA55 AS <br /> T 9 'o(\d) lin' <br /> R INSURER (1-cn J ..g•L1�•^ i�( I (J�Q �ctK WORK.COMP.# ff�C��8�• O <br /> A <br /> C FIRE DISTRICT a M a ` PERMIT # <br /> T J <br /> 0 LABORATORY NAME V�/n�Irp At CWNTY S PHONE # �o_ S' <br /> R N <br /> SAMPLING FIRM �(� T1JL PHONE #111111111111111111111111111111 <br /> �O� yy(o_79S10 <br /> TANK ID # TANK SIZE CHEMICALS STOR CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- ID ,000 Cn.Ll e.•� ��¢5e f��o-7 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L \ (� APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A _ CSIONS BELOW AND/OR ON ATTACHMENT) <br /> N ) \ {\\ QQ <br /> PLAN REVIEWER'S NAME DATE tla <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." 5 p <br /> APPLICANT'S SIGNATURE L/��� TITLE"rO\P0 DATE �) O <br /> 13 <br /> CONDTTION(S): � a-�-_ _Q _ _ 1 �/ ,,,�}1-' \1„ _ � ►,r�., <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />