Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERK UT <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # C fiC oo/a/II X//.;z <br />F FACILITY NAME O 9- , 4V\ tl O <br />A <br />C ADDRESS S6 GC%A C2 G <br />I <br />L CROSS STREET V Zh is C <br />leI <br />TMD <br />PROJECT CONTACT & TELEPHONE # m� <br />.s-t61C <br />T OWNER /OPERA <br />Y SAm d- /ilA2/� /� 621orld/b <br />C CONTRACTOR NAME <br />0 <br />N CONTRACTOR ADDRESS 3 02�s,L e c S G <br />T qs6 <br />R INSURER F Tz L Vh6,^-� Co=pgJaSeA� Dye <br />A <br />C FIRE DISTRICT W0100 - YY�OPu�(i 5��• <br />T <br />0 LABORATORY NAME G L S COUNTY SCLC <br />R <br />SAMPLING FIRM GRa�J�uN� �V�vi2ov�il�ncw�cc� <br />Ilillllllllllllllllilllllillll <br />T NK D # TANK SIZE e <br />39- O o _ <br />T 39- r <br />A 39- - <br />N 39- - <br />K 39- - <br />39- - <br />39- <br />II111f111111i11l11 111111 lll! 111 1111111111111111 1111111lIIl I <br />PHONE #( <br />sa 4:5PHONE # <br /><aa <br />PHONE # <br />3�3 <br />43i- a 95 <br />.3�a - l88e <br />CA LIC # 6 72 a 3 g CLASS <br />WORK.COMP.# w1 <br />V i <br />PERMIT # F P- <br />C V� PHONE # <br />a -mc 9�0 � <br />PHONE # <br />CHEMICALS STORED CURRQNTLY/PREVIOUSLY <br />60c>3(5 C <br />638--730/ <br />Fs6 - /yy/ <br />DATE UST INSTALLED <br />��Irtrno�uv� <br />q <br />P <br />L APPROVED APPROVED WITH CONDITIONS) _ DISAPPROVED <br />A ( EE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME ' DATE <br />11111111111111111111111111111111111111111l11111111111111 ill Iliilflllillllllllllll111111111111111111lI1111111111111111111111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERF NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIF <br />r <br />APPLICANT'S SIGNATURP: TITLE A f -c k - Cc rnQraJ DATE b <br />rn�1�c. I_ce. <br />CONDITION(S): I-' <br />_ <br />� a � 1' -&W` 07—� fir ` �zv <br />EH 23 046 (Revised 7/10/96) Page 3 <br />