COMPLIANCE INFO_1991-1994 - Laserfiche WebLink

Home Browse Search

ENVIRONMENTAL HEALTH DIVISION APPLICATION FAR UNDERGROUND STORAGE TANK CLOSURE PERMIT APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDON14ENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE EH 23 046 (Revised 7/10/92) Page 3 EPA SITE # PROJECT CONTACT & TELEPHONE F FACILITY NAME PHONE # A C ADDRESS I L CROSS STREET I T OWNER/OPERATOR PHONE # Y C CONTRACTOR NAME 'PHONE # 0 N CONTRACTOR ADDRESS CA LIC # CLASS T R INSURER WORK.COMP.# A C FIRE DISTRICT PERMIT # T 0 LABORATORY NAME PHONE # R SAMPLING FIRM PHONE # 111111111111111111111111111111 TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- 3 39- A 39- N 39- K 39- 39- 39- InT 111111111111111111111 P titt11111111111111 L ® APPROVED APPROVED WITH CONDITIONM _ DISAPPROVED A (SEE ATTACHMENT WITH C OND ITIONS) N PLAN REVIEWERS NAME I11111llllltllltllll DATE Intl APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." TRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: at CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE DATE EH 23 046 (Revised 7/10/92) Page 3