Laserfiche WebLink
1t <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERI-UT FOR PERMANENTITEMPORARY CLOSURE OR AOANOONMENT IN PLACE OF UNOERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES gU DAYS FROM THE APPROVAL DATE. OO NOT WRITE IN ANY SHADED AREAS. INOICATE PERMIT TWE: <br /> ❑ REMOVAL C& TEMPORARY CLOSURE ❑ CLOSURE'IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE= JPROJECTCONTACT 80 WA6P-J PHOYS 9LNE5ZS57-1 <br /> ME <br /> FACILITYNA ?R&AQ%C 1&2,1,L PHONEY 2 82'5 Sb66 <br /> ADDRESS 7.5oc E.C-sr E•. [TT rn,%a <br /> CROSS STREET <br /> OWNER OPERATOR R1U ALL Bu 1 $01. 5M5' /LYn 'S[AOD, SPA 4mon `tY333 PHONE# /!23'b23 A9E.G <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME LIIrI I PHONEY 70-7 '!4'I 664 <br /> CONTRACTORADDRESS -( L JOU Tlna.( We& SI,O CALICY CLASS AIN <br /> INSURER HG (..m w,5c Dr I v a.rti FL" WOR7(ER COMP« p b3 <br /> FIRE PI5TRJC7 In- a r PERMIT# 'GcOvLrb <br /> LABORATORTNAME II,11.0 COUNTY PHONEY 1 <br /> SAMPLING FIRM PHONE A IA- <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS IPRESI PAST DATE INSTALLED <br /> 39- /D OOtJ 6Q sol l-c- N x+ ✓ <br /> 39- ou0 I <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICM+r AOJST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,FEDERAL LAWS,AND RULES AVO <br /> REGULATIONS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENPS SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WFYCIN THIS PERMIT 15 ISSUED,1 S:ALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'5 COMPENSATION LAWS OF CALIFORNIA: CONTRACTOR'S HIRING OR SUBCONTRACTWG SIGNATURE CERTIFIES <br /> THE FOLLOWNG'. T CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WHICH THIS PERNUT IS ISSUED.I SH LL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S CO ENSATION LAWS <br /> /JOF,{rJ,LIFORNIA'����j <br /> APPLICANTS5IGNATURE Fes" - " �\'(IG((�I(�TITLE/I/ll, �PGi C.IX�C'V� A7E /1-2G"02- <br /> ❑ APPROVED 0 APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S �Fd> DATE �a O <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST HE SUBMITTED TO ENO FOR APPROVAL PRIOR TO COMMENCING WORK, <br /> CONDITIONS: <br /> EH 23 048(REVISED 001131 1 Paga 3 <br /> 12/10/02 TUE 09: 43 [TX/RX NO 87091 002 <br />