Laserfiche WebLink
�l <br /> S� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY,2COSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYSFR THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # /A-Uoo Q PROJECT CONTACT S TELEPHONE <br /> F FACILITY NAME �S PHONE <br /> A <br /> C ADDRESS n C <br /> 1 <br /> L CROSS STREET <br /> 1 <br /> T OWNER/OPERATOR PHONE # <br /> Y d lokfL/ <br /> C CONTRACTOR NAME '�� O w/ PHONE <br /> N CONTRACTOR ADDRESS , � ' 'Z�e`i.� ,�,� CA LIC # Z�..6�5 CLASS <br /> T �aI <br /> R INSURER iwnsszorL "Ty WORK.COMP.# 2�9FD1053Z <br /> A <br /> C FIRE DISTRICTG� �� PERMIT # <br /> T *� <br /> 0 LABORATORY NAME I,J \V�DA�t, PHONE # Zal) S - '1bS6 <br /> R <br /> SAMPLING FIRM PHONE 9 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- D- G <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- -------- <br /> P P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE AT HMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND LESjTIFIES <br /> FFCLLOWIN <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLO ING <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE"I CERTIFY THAT IN THEPERFORMANCE0 THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE / TITLE DATE <br /> 10 <br /> EH 23 046 (Revised 7/10/92) Page 3 V <br />