Laserfiche WebLink
iENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT MOIJ'lj C�� <br />APPLICATION FOR PERMANENT/TEMPCRARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />ptiSRzn-z�t' 4 Rptnc,� <br />V <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE RepUaGe m enT <br />EPA SITE : PROJECT CONTACT I TELEPHONE 9 <br />CAL 000 035 305 - Lou PAR►51 IR16- roPl1- &CE 15 65P 016) <br />FACILITY NAME P OIL. PHCNE ZO - 855 - S3 <br />ADDRESS <br />t 2.3-15 TRACY BLVD TI24C-Y I G <br />CRCSS STREET _ , n <br />OWNER/OPERATOR PHONE <br />FARA PAKz.AD 209- 855- 535`d <br />CONTRACTOR NAME / �ARAD�SC7 Gd ST CTt ►tel PHONES <br />CONTRACTOR ADDRESS SAN LrmA► Q%%b, CA LIC A ZS982O CLASS <br />Po 3(0 rs�� A.5&0. r --(W Q-40 <br />INSURER9J2. .-I �� l llrl�i * Co . WAL.NUT GREEK. Gp %roRK.CCMP.� PG 994559 <br />FIRE DISTRICT PERMIT 0 <br />tr�SP¢,«'on <br />LABORATORY NAME P I PHCNE 22z- 300 2 <br />JUR)bkQ L_ TIc.6L 415 <br />SAMPLING FIRM als�h� UGO IPr1C� PHONE 5(O 0082- (`�82 <br />III II II] 111111111Ill 11Ill 11Ill <br />TANK IO CHEMICALS STCRED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br />39- :` Pel N 6, c>oL.. <br />39- <br />39- <br />39- <br />39-� <br />39- <br />39- <br />111111111I11I1llllll1l11Illlll Illill]Illlllllllllllllllllllll! 1111111111]IlllllllllllIllllllllllll]ll 1llllllllllllllIlllU <br />XAPPROVED APPROVED WITH CCNOITICN(S) _ DISAPPROVED <br />(SEE ATTACHMENT WITH CONDITIONS) <br />PLAN REVIEWERS NAME DATE L 1 <br />I I l l l 111 11 111111111l 11 l Il 1111I I l l I I 11111111111111111 111111111111111111 Hill 11111 ll l]l ll 1111111 Ill !I Il l ll ll1 ll 11I 11 ll 11111 ]11 <br />1PLICANT MUST PERFORM ALL WORK IN ACCCROANCE WITH SAN JOAQUIN COUNTY ORDINANCCES, STATE LAWS, AND RULES AND REGULATICNS OF <br />:N JOAGUIN CCUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY THAT IN <br />:E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />?BJECT TO WRK-ER'S CCMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />MPENSATICH LAWS OF CALIFCRNIA." <br />PLICANT'S SIGNATURE: �F�/F-,'T`�� 1 ��_.l ll�l�TC- TITLE R101ga ' MANA4a2_ DATE i 2 92 <br />3 046 (Rev 2/8/91) '; Page 3 <br />