Laserfiche WebLink
r <br />• <br />i <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE _!�,, � PROJECT CONTACT & TELEPHONE # Fa0l 5,2rr-eft 14ij &51 ` 7711 <br />FACILITY NAME Southlard 7 -eleven PHONE # <br />ADDRESS 272Gj count"GIU6 �j1vGi• �"�®G1et'Dr1 <br />CROSS STREET Ryde, <br />OWNER/OPERATOR -Th 5o�ftNana <br />PHONE # <br />(9*) (d-51-7711 <br />CONTRACTOR NAME Mqr e-5., GorpI >ratl �C) I <br />PHONE # A,-/-,7) �iS- 4 rj <br />N CONTRACTOR ADDRESS 41CU4 E. �rini3 5t'rc6t', Long bcah CA LIC # S53lv33 CLASS GI2G z �7 6e�7 <br />T WORK.COMP.# WC817°103(a <br />R INSURER N;;t. Union Fire 41s. CO. <br />A I PERMIT # <br />C FIRE DISTRICT <br />T <br />0 LABORATORY NAME WPS{ 4.G60r5+t>rt&S COUNTY ` oIC> PHONE # (�I!!> 7S7 -p�20 <br />RSAMPLING FIRM FlPHONE <br />uor - L7ant�l� C�Tt <br />111111111! 1111111! I I 111111111! <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY GATE UST INSTALLED <br />39- I 7 <br />T 39- L7 -G jr aad— <br />A 39- 10,220 111E <br />N 39-rU Prcw+i�r+yn e a i972 <br />K 39- <br />39- <br />39- <br />111111111111 III11 11 I III I I 11 !I I Il ll I I l I III III II11 111 I 1 1111 IIIIIIIII11111 <br />P <br />L APPROVED _ APPROVED WITH CONDITIONS) _ DISAPPROVED <br />A SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N Gam_= DATE ` <br />PLAN REVIEWER'S NAME <br />11111Illlllillllllllllll111111111111lIl111111lliIllillllllll!!l!!11lI1llll1ll![Illlllllllllll!!l111111111111IIllll11111i11111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANIS REGULATIONS OF <br />SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S: <br />COMPENSATION LAWS OF CALIFORNIA." _ jy 1 <br />¢ r1V � GIJfI} '2M <br />APPLICANT'S 5IGHATURE�/ "- ` �t7 QNL G�"jjG�� TITLE DATE '�" 1 �IP� <br />CONDITION(S): <br />EH 23 046 (Revised 9/11/96) Page 3 <br />