Laserfiche WebLink
ENVIRONMENTAL WEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERNANENTJTEMPORAkY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND RAZARDOUS SUBSTANCE STODGE TANK <br />THIS PERMIT EXPIRES 9D DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN AMY SHADED AREAS. INDICATE PERMIT TYPE BELOW. <br />REMOVAL �•_, TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA $1 TE 9 CACCoo a -JCI I -V-6 <br />PROJECT CONTACT A TELEPHONE <br />F <br />FACILITY NAME SUByasA-tJ AaypA-tic PHONE / apt/)V:. 52115- <br />c <br />ADDREss 23901 S. CH'12.ISMA7p1 fit)' <br />L <br />CRIBS STREET E7,a7 �/ - �m�,+g•r <br />T <br />OWNER/OPERATOR PHOIF M <br />T <br />I SIA8uY-6A-u �s 0 616'4-5301) <br />C <br />CONTRACTOR NAME ALL EUVV120NM1L'T1'i'».T_r INC PHONE I(3')820322.'' <br />N <br />CONTRACTOR ADDRESS ?to Ldl CROW (,ANyoA) L7Q. STD-: 5 CA LIC N 495yg19 CLASS A 4AZ A -r.5 <br />R <br />INSURER STA'M Tl1N[? WORK.COIP.S 13310 105-- qy <br />A <br />C <br />FIRE DISTRICT PERMIT N gy01O- <br />7 <br />O <br />LABORATORY MAKE S r lric-: .. PHONE <br />SAMPLING FIRM OpST.Ttoc- PHONE Cr - 238'! <br />I11111I I11 <br />TA4711111D �11111lI1I11 <br />TAMC TANK SIZE CHEHIGALS STORED CURRENTLY/PIffiY[OISLY DATE UST INSTALLED <br />39• ✓l/on (ASrL..I(�jid IiXK <br />i <br />39- <br />39- <br />- <br />N <br />K <br />39- <br />_ <br />...._ <br />39- <br />-'-- <br />t ! `ffffffmmTrfffffffffffffffffffffflffiffffffffffumTFTM <br />liii I 1 <br />P <br />L APPROVED APPROVED WITH CONDITIONS) _ DISAPPROVED <br />A (SEE ATTACHMENT WITH CONOIYIONSI <br />M PLAN REVIEWERS NAVE DATE <br />111111111 lill 11111111 11111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOIIQUIN COOITY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED A(WENT'S SIGNATURE CERTIFIES THE FOLLOWING. "1 CERTIFY THAT IN <br />THE PERFORMANCE OF YHE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT E17PLOV ANY PERSON IN SUCH A VAINER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR "CONTRACTING SIGNAYURE CERTIFIES TOE FOLLOWING_ <br />"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />I <br />APPLICANT'S SIGNATURES 4---, /R-tm �'�. TITLE M/Ftr A44Y.Mt iK_ DATE <br />