ARCHIVED REPORTS_XR0005283 - Laserfiche WebLink

Home Browse Search

COUNTY PUBLIC HEALTH , SAN JOAQUIN COU SERVICES ENVIRONMENTAL HEALTH DIVISION ' APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE0, I STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE DO NOT WRITE IN ANY SHADED AREAS INDICATE PERMIT TYPE �- REMOVAL - v---r -- ❑_-TEMPORARY CLOSURE LOSURE IN PLACE- - FACILITY INFORMATION EP TE PROJECT CONTACT PHONE# b Z Y NAME PHONE# ' ADDRESS CROSS STREET OWNER OPERATOR PHONE# CONTRACTOR INFORMATION USURER NAME PHONE# 5 ADDRESS L ' A LIC # CLASS a RKER COMP# 141 A, 8ORATORY NoAE S I COUNTY PHONE# Z- -2 Q PHONE It TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS (PRESENT& PAST) DATE INSTALLED 39- gbO 39- 39- 39- 39- 39- r APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LA�[1 &rF$OE.RAL LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES OWNER OR LICENSED AGF-H GNATURE CERTIFIES THE FOLLOWING I l CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISS OT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER S COMPENSATION LAWS OF CALIFf3RNIA' C9bLT TORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES. THE FO.LOtvINS t CERTIcY T IN TH E OF THE WDRK-�17VV1 ICH THIS PERMIT IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKER S COMPENSATION 1AW ALIFORNL4 mm -- [ �{� APPLICANT S SIGNATU TITLE 01`'' __DATE 1 " ❑ APPROVED APPROVED WITH CONDITION{S} ❑ DISAPPROVED (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) PLAN REVIEWER S NAME - - _ - - _ -- - -- -- =LL — DATE- ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL.PRIOR TO COMMENCING WORK CONDITIONS. - a•� - - may° - - -