Laserfiche WebLink
j <br /> F <br /> SAN JOAIN COUNTY PUBLIC HEALTH SEF ;ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZAROCUS SUBSTANCES <br /> ST,CRAGE TANK{S) EXPIRES 90 OAYS FROM THE APPROVAL DAT='. ❑O NOT WRITE IN ANY SHACED AREAS. INDICA i=PERMIT TYPE: <br /> s <LgrREMOVAL 0 TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION _ <br /> RA SITE#0/4 C-L:.=L~jt.! -61-444- PROJECT CONTACT <br /> rAC:LITY NAME 2pc-o; <br /> ADDRESS 43 z - T x�C'� ,'a 0 <br /> CROSSSTREE�i <br /> � ?HONES <br /> DOWNER OPERATCR �'f' 72):-r <br /> CONTRACTOR INFORMATION <br /> CCN T RAC'=OR NAME 1 tet: j HONE *I:icGr <br /> ` I CLASS <br /> CONTRACTOR ADORESS <br /> INSURER L'%L�k~ -t�"h: ' rA:bE3�"1i:L I I WCRKER COMP# "I 4:.Ql, <br /> FIRE DISTRICT 1 Ll PERMIT <br /> f , - COUNTY- rHJ. �itr'� j ?HONE <br /> - .P-ORATORY NAME �C'A�� <br /> SAMPLING FIRM �� % 'l II C`M -,Aa, <br /> , l ?HONE <br /> TANK INFORMATION <br /> TANK!D# TANK SIZE TANK^,C;NTENTS iPRESENT 3 PAST) ! DATE E:NS iAL�=J <br /> � 39— , � /u Cc��; t� I <br /> RAL i_AvyS.AND RULES AND <br /> i 39—./y"J' 1J L. %ri�ir�+ t�G( tZ <br /> 139- <br /> 39- <br /> 139- <br /> —,A—,,= <br /> 9- <br /> 30- E <br /> 39- <br /> 39- <br /> ORDINANCE <br /> APPLICANT FAUST PERFORM ALL WORK IN AC;CRDANCE WITH SAN JOACUIN CC UN CENSE'J AG£N S SIGNATiJR£ C IFIE THE FOLLOWING. 'I <br /> REGULATIONS OF SAN JOAQUIN <br /> COUNTY PUBLIC HEALTH SERVICES. OWNER OR Ll IS ISSUED.! SHALLNOT EMPLOY ANY.o_RSON c IN 5UG`t A MANNER A5 <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT <br /> TG BEGONE SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THUS PERMIT IS ISSUED.I SHALL MMPLOY PErZSCNS SUBJECT TO <br /> 'NCRKER'S COMPENSATION LAWS OF CAUFORNIAL' <br /> 11 / <br /> L.. OATE� I <br /> APPLICANTS SIGNATURE ' - <br /> ❑ APPROVED APPROVED WITH CONDITIONS) ❑ DISAPPROVED <br /> n (SEE CONDITIONS BELCW ANDIOR ON ATTACHMENT) i <br /> oATE <br /> PLAN REVIEWER'S NAME_ ( <br /> ANY OEVIATYONS FROM THIS APPUCATION MUST$E SUBMI I I ED TO EHO FOR APPROVAL PRIOR TO COMMENCLNG;IYORK. <br /> CONDITIONS: <br /> iL <br /> i `✓ f <br /> ! I <br /> i <br /> ! I <br /> i <br /> Pace(RE°JISEO 10l 9198) <br />