Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EYVIRONNLEiENTAL HEALTH DR/ISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PER.N= iI` <br /> i.. THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZAROQIS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 GAYS FROM THE APPROVAL DATE. DO NOT 'WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELCW: <br /> I <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> 7�- <br /> I PROJECT CONTACT 3 TELEPHONE f <br /> ME T <br /> IE.-:AC , o J C(�- I PMONE C ! f <br /> 6c7 _ I ✓CI T n ? 7 �//'TOR PNONE <br /> Y 1 109 cw����j2 D>-ioo7- <br /> C I CONTRACTOR NAME <br /> OC - I PHONE { <br /> N CONTRACTOR ADDRESS <br /> �Yo L� <br /> ? G 6�L/1'/OIJT �1iG�;I G LIC X ��S SrO CLASS//IC <br /> INSURER 57—,4 / �J�LI /•I.�r L '. �"i-C-I�� 40RK.CCMP.,. <br /> TFIRE DISTRICT ��/•!� ` I PERMIT <br /> 0 LABORATORY NAME (• I COUNTY I PHONE T <br /> I SAMPLING FIRM PHONE <br /> 39- <br /> lllllllllllllilllll11111111111 <br /> TANK ID TANK SIZE ( CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br /> (I <br /> T 39- <br /> A i939- <br /> Oo <br /> Co <br /> �-- - <br /> P II11111111111 11!1111 I I III 1 I III Illlllllllill 111 !111111 11 111111 11 111111111111111111111f11�lllllllflllililllllll <br /> L APPROVED APPROVED WITH CONDITION(S) BMDISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACERT) <br /> N <br /> ?!AN .REVIEWER'S NAME <br /> OATS <br /> nlunutunnnlnnnluullllllrlllrlllllrlllllrrlllllrlfllllllllllllunnnunnnununnllulunnnu►unnnl � <br /> [AP;QLICANT'S <br /> PIICANT ,MUST PERFORM ALL 'WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF ! I <br /> N JOACUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AG'ENT'S SIGNATURE CERTIFIES THE FOLLOWING. "1 CERTIFY THAT IN <br /> E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> BJECT i0 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLCUING:; <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL -EMPLOY PERSONS SUBJECT TO WORKER'S j <br /> MPENSATION LAWS OF CALIFORNIA." i <br /> SIGNATURE: n / ' <br /> TITLE ('Cc���'�i� .OAT'e <br /> is I <br /> CONDMON(S): <br /> Yx <br /> EB 23 046 (Revised 9/11/96) Page 3 , <br />