Laserfiche WebLink
Q CLOSURE OR 2 NDONMENT Q Telephone (2209) 468-34M <br /> QQddddQdOQQddQddQQddQdd.^,QQQdQQdQdddQdQddQdQQdddd7dddpdddddQddddddQ If <br /> � �moN FOR PEP,MANENt/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTAORAGE FACILITY <br /> PERMIT EXPIRES 30 DAYS FROM TyE APPROVAL DATE. BO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT IFE BE*0 1989 <br /> ---/- R/EMOVAL ----- TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE ENVIRONMENTAL HEALTH <br /> PERMIT I S I ES <br /> EPA SITE 1ff <br /> PROJECT CONTACT L TELEPHONE 1 <br /> CF FACILITY NA PHONE 1C ADDRESS 1/ oN_T Y� �Tacl�rc J CA _ >s�o <br /> L CROSS STREET <br /> I <br /> T OWNERIOPERATOP. PHONE I <br /> Y6 <br /> C CONTRACTOR NAM PHONE I <br /> a J <br /> N <br /> CONTRACTOR ADDRESS$ AdIo CA LIC 1 Q5 CLASS <br /> P. INSURER <br /> A - - — WORK.COMP.1 <br /> C (IRE DISTRICT PERMIT 1/INSPTR — <br /> T C F .Smc%�-- <br /> 0 LABORATORY NAME PHONE 1 <br /> R UG .� , <br /> SAMPLING FIR M•C � SAMPLING METHOD <br /> � <br /> A'' f2.4� T <br /> TANK ID 1 <br /> T TANK SITE CHEMICALS STOPED CURRENTLY CHEMICALS STOPED PREVIOUSLY <br /> A 33--1Q59q_=01--------- -- —L—S ��+�IL,�STC� G✓ASrE Orc �rtS7T��iL <br /> N 31- <br /> K 39 <br /> ---------------------------- <br /> 33- <br /> ---------------------------- <br /> 33- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P APPROVED ...APPROVED WITH CONDITIONS DISAPPROVED <br /> L ---- <br /> SE ATTACHMEN KITH CONOITIONS) <br /> A PLAN REVIEWERS NAME <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: - <br /> I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL F41 SP TI NS AT LEAST 413 HOURS IN ADVANCE <br /> _ — q <br /> --------- ---------- - — DATE / <br /> SIGNED --------L--[ - Ye.E -� � <br /> OFfIC[ USF ONIY - - --------------------- --------------------------- <br /> it$$ismssiifiifsfflsftiStlstts{ismitltstsssst{fss{IIsiit{isfsisftf{fsstts{ff{fSfstfftfifttffiffttfiffsffffsffffffffiis <br /> SWEEPS 1 ' COMP I 'LOC CODE 'DIST CODE AMOUNT DUE AMOUNT KCVO G,F.I/CASH KCVO BY I DATE PCVD I PERMIT 1 <br />