Laserfiche WebLink
SAN JUIN COUNTY PUBLIC HEALTH ,VICEs <br /> P <br /> SIVIRONMENTAL HEALTH DIVISI <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE.- <br /> REMOVAL <br /> YPE:REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# -IS PROJECT CONTACT S&12T PHONE# SBO- :La <br /> FACILITY NAME 92 6 A PHONE# <br /> ADDRESS <br /> CROSS STREET t <br /> OWNER OPERATOR 1 PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME L e PHONE# <br /> CONTRACTOR ADDRESS , CA UC# CLASS <br /> INSURER t VVORKER COMP# • <br /> FIRE DISTRICT 5ZD29s PERMIT# <br /> LABORATORY NAME Lrs COUNTY Y Q t.C, I PHONE# tj <br /> SAMPLING FIRM Eck PHONE # <br /> TANK, INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- z <br /> 39- f - o 3 1 <br /> 39- �? <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'i <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,i SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS CAUFORNU.' <br /> APPLICANT'S SIGNATURE C2 h TrrLE (. secfwot.c. ✓ DATEJJ:-. <br /> ❑ APPROVED ;I-APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW ANDNOR ON ATT <br /> PLAN REVIEWER'S NAME DATE (Z1rs/ ' <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENgNti WORK. <br /> CONDITIONS: <br /> r- v fir, r, rlsaCic t/f tG rrn / r_;_1_��el <br /> (ICC <br /> EH 23 046(REVISED 10/1"8) ` <br /> -q),4 Ml r7r m U 90 1 h 5� �u� �'" t eco I ez 0Cyo <br />