Laserfiche WebLink
I <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />c <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />1 0 0 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL7E. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />�// REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE <br />FACILITY NAME fl V� /� �-tQ "4�- 7; PHONE # 2OL) -4G+ -to'-36 <br />ADDRESS <br />CROSS STREET <br />OWNER/OPERATOR <br />m-. , , cA R S2os, <br />, I NG . <br />PHONE # Skb - �r1- - ssoO <br />CONTRACTOR NAME PHONE <br />l-}-byt E n G i h E tZ i n� G T c, <br />CONTRACTOR ADDRESS CA LIC # 6 �.Z a 3 8 CLASS L <br />R , 13o fv Se�G S6 / "� <br />INSURER GaI j ��lrI , �n5 WORK.COMP.#��� <br />FIRE DISTRICTGrA-Ll� ()S-roc-v-�o <br />LABOR}iTORY AME SUPE �OlZAN�Z�4' COUNTY SffZAt`c�TO <br />s-�,_•T� 117 <br />_% <br />SAMPLING FIRM tp +�cri' coMeL,iXoZclos rLz- <br />Illllltlllllllllilllllllillll ;WAFL my <br />TANK ID # ,OiSIZE CHEMICALS <br />39- <br />—nom I I h , 00 l7_ ►% <br />39- <br />39- <br />39- <br />39- <br />39- <br />1111 <br />PERMIT # <br />3-116 <br />-?<3b -oO <br />PHONE #G(k(Q -q2_\ -q'(OW <br />PHONE # SIO-4�L(Q <br />CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />,S OL-%" V --- <br />APPROVED <br />APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />( EE CONDITIICN�S BELOW AND/OR ON ATTACHMENT) <br />.J C <br />PLAN REVIEWER'S NAME ���/ DATE <br />-wC Y i <br />�I1111111111l11111111111111111111111111111111IIIlillllll1111I1�ll�llIllllilllll1111111111i11II1u1111111n1111111111111111111! <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 COMPENSATI LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERf0 ACE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFO IA.' <br />AP -C ak - pt -f -j'- <br />APPLICANT'S SIGNATURE: _ TITLE I`t�P�NPrC/� DATE <br />CONDITION(S): _ I I <br />Is <br />®�� sM-r.6 �-s o <br />51, <br />EH 23 ;46:(We.d7/10/96) Page 3 <br />