Laserfiche WebLink
j 1 ��� � � x { � 1 EIZ4! irortrtiecZi: � � i--� � � itl. f <br /> fool, 0 <br /> F-1 w ; t <br /> RECEIVED <br /> DEC 19 2023 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT ENVIRONMENTAL HEALTH <br /> PERMIT/ SERVICES <br /> THIS PERMIT FOR PERMANFNI /TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS <br /> SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS , <br /> INDICATE PERMIT TYPE : <br /> 14 REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION �f <br /> EPA SITE #�-/46Qf�i' Z�y PROJECT CONTACT /lillefor 7 !t`a'Ol� ��% PHONEiI � Q�'— ✓�e�__� <br /> FACILITY NAME i/L. ': lz G�I S T PHONE <br /> ADDRESS _ S 64 Pi CC � 412 <br /> � — <br /> CROSS STREET <br /> OVdNER OPERATOR (j 0 1 L ' ^ G PHONE itZ- 5 D� <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME II f � 1 ,C LQ . � ,I PHONE ii i <br /> CONTRACTOR ADDRESS C ,� G 2 ! CA LIC: 11 CLi1SS <br /> INSURER AiFf 1 D 1": CX f' Fr _. � �/ t{ WORKER COMP# r �i5�� ' I` t�• 7 s'.' <br /> FIRE DISTRICT gf t 7 t IC' PERMIT #t &�,VDAV <br /> r 0� COUNTC ✓litCtSMPHONLABORATORY NAME E # Z <br /> SAMPLING FIRM I L 7/oj <br /> 1zpgFfle /Vooveff D <br /> TANK INFORMATION <br /> TANK ID # TA K SIZE. _ TANK CONTENTS (PRE �NT AND PAST _ DATE INST LLED <br /> _ 4l <br /> 39- © . ni/C,�Q�rd'.Gv�,n! _ Ci' f 41 <br /> 39- __. . - _- -- — <br /> _ <br /> 39- — --- — -- - <br /> 3910% -- <br /> 39- - <br /> APPLICANT iNiU3T PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS , FEDI: RA1- (.AWS , AND RUI FS AND <br /> REGULATION. Ot' SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DI-.J'ARTMENT. OWNER OR LIGLNSED AGENTS SIGNAIURE CERTIFIES THE <br /> FOI LOWING; " I CERTIFY TI IAT IN -EI lE PERFORMANCE OF TI IC WORK FOR WHICH THIS PERMIT IS ISSIJFII , I SHALL NOT EMPLOY ANY PERSOIJ IN SUCH <br /> A MANNER AS TO BECOME' SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. " CONT'RACTOR'S HIRING OR SlJBCONTR.ACTINc ; <br /> SIGNNIURE CERTIFIES THE FOLLOWING : "I CERTIFY THAT IN THE PERFORMANCE! OF THE WORK I' OIl WHICH THIS PERMIT IS i9sum , I .SHALL <br /> EMPLOY PERSONS SUBJECTTO WORKER 'S COMPENSATION LAWS OF CALIFORNIA " ¢ <br /> APPLICANT'S SIGNATURE � :�_' . TITLE <br /> ❑ APPROVED SIAPPROVED WITH CONDITION ( S ) ❑ DISAPPROVED <br /> 03F EEIONS BU: LOW ANNWOR ON Ai f A(;HMrNNT) <br /> PLAN REV IFWE, R'S NA C G r ' Fee. pltle ' l N,01) UA 11= <br /> ANY DEVIATIONS FROM THIS A ( CATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS : <br />