Laserfiche WebLink
v <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> Cd REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> EPA SITE# PROJECT CONTACT PHONE# Q a <br /> FACILITY NAME G Yl - PHONE# <br /> ADDRESS O 5 <br /> CROSS STREET <br /> OWNER OPERATOR L� Zi(� PHONE# <br /> CONTRACTOR NAME - O 5 <br /> CONTRACTOR ADDRESS' CA UC# o�J CLASS YMM IA-7 C ) <br /> INSURER =i j Cm ` Com Fuv WORKER COMP# 37 Q2 <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME COUNTY 0C 4 PHONE# �2S 7Cjgj- `G20-1 <br /> SAMPLING FIRM PHONE # ( - ©70 <br /> TANK ID# TANK SIZE <br /> F39- <br /> 1777777 500 <br /> 39_ <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE <br /> FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY <br /> PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br /> � <br /> � w s <br /> APPLICANT'S.SIGNATURE 1`� Q 11J TITLE Vu ATE 12G <br /> ❑;:APPROVEtf <br /> PLAN REVIEWER'S NAME- *' <br /> ANY DEVIATIONS'FROWrtISP� A <br /> y , <br /> ix,k42 ' t,e✓, S 2 -E+ckn�d'C''�k.�: -,C..0l�� n- .,k <br /> EH 23 046(REVISED]0/16/03) Page 3 <br /> ]. (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES[] NO[] <br />