Laserfiche WebLink
SAN JOA IN COUNTY PUBLIC HEALTH SWICES <br /> EN;w'IRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPOPARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S) EXPIRES 90 OAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE. <br /> REMOVAL 0 TEMPORARY CLOSURE 0 CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE PROJECT CONTACT —p <br /> 4— s PHONE/s <br /> '241)'-so 0 - 161!y-oMy�Aw /0'2, <br /> FACILITY NAME -54911 Q',1 C.Al Z-j 'e,,Z' f!i e-s Z -T-c PHONE-0 !9z-$7-33-s-- 5-cloo <br /> ADDRESS 1560, v)c-roA, 1 10-4-0 <br /> CROSS STREET aja�kmd'v <br /> OWNER OPERATOR C 1,0-<4Fb PHONE 9 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME SfI p -A/c I PHONE Slo <br /> CONTRACTOR ADDRESS <br /> CA LIC# 0 CLASS <br /> INSURER C'OL)8116' VVORKrzRCOMP* --jy5,�_j04/3-/ Ce$leA Z c (o <br /> FIRE DIST g 7— <br /> PICT Flear T PERMIT A <br /> LABORATORY NAME -<E--Q0(01A AAMLY'rICA4- PHONE 4 6sr— 3 <br /> SAMPLING FIRM f-'AolA2i,4 FAlVjaoMr-,Nr1 1112C 0 - �y-q?,z-z- <br /> t4 PHONE It -1'/0 . <br /> TANK INFORMATION <br /> TANK 10 a TANK SIZE IFANK CONTENTS(PRESENTA PAST) OATZINSTALLED <br /> 39-,So L- 5, 0406677 0Af <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STAT-c LAWS. FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE C?RTIFfi!S THE FOLLOWING: 'I <br /> CERTIFY THAT IN THE PS.RFCRMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO 3ECOME SU8JECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.* CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING. -1 CERTIFY THAT IN THE PSRFORLMANC- F THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF OR <br /> APPLICANT'S SIGNATUREE <br /> TITLE XaM61 A6'12- _DATE 14v:;Zoo-t4? <br /> L <br /> F0OlA AREVIEWER'S NAME <br /> APPROVED APPROVED WITH CONDITION(S) 0 DISAPPROVED(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN <br /> f� DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST S S MITTED TO EHO FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> Ica& <br /> i VLA4A'l A <br />