Laserfiche WebLink
F <br />EPA Site # <br />Project Contact & Telephone # <br />-FacIIIty;•Name `. <br />Phone#2M <br />L <br />Address <br />_Crow5treef <br />T <br />Y <br />Owner/OperatorPhone <br /># 14 _ <br />C <br />Q <br />_ <br />Contractor Name <br />Phone # <br />_. <br />T <br />Contractor Address <br />- <br />111Mc <br />CA Li# Class <br />A <br />InsurerIUM6P%Work <br />Comp # <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />A <br />o .. <br />R <br />ICC Installer's Name .. <br />Expiration Date <br />_. <br />Tank system work area <br />(i.e. B7 piping sump, 91 leek detector, UDC 112, etc.) <br />Tank Size Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑.Approved <br />❑ Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date <br />PERFORM ALL WORK IN ACCORDANCE WITH SAN JOA( <br />, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR <br />COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />NSED'AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />L.NQT EMI'oY A -Y - <br />.PERSON IN sucH A MANNER AS j0 $ECiJMf< $UB IEGT.TO <br />OR SUBCONTRATING SIGNATURE CERTIFIES .'jHE, FOLLOWING .'I CERTIFY' <br />C, I SF{ALL EMPLOY PER$QNS SUBJECT TO WORKER'S COMPENSATIQNlAW9 <br />a <br />