Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> ❑ REMOVAL G& TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT 8 D f.VAb P-O PHONE# Q25 ZS&21 J3 <br /> FACILITYNAME Ppp ci,F(- 94," PHONE# 42 2"> 52,66 <br /> ADDRESS 2'600 `GL'-Sr E, Inr mAe- O <br /> CROSS STREET <br /> OWNEROPERATOR RiL,Ac- 62,1• Po $qt SZQS' RVn 3£000 5p,%qAmvn `6 M3 PHONE# g2TS2-% 8966 <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME JGf aLPHONE# 707 ?4? 661?lt <br /> CONTRACTOR ADDRESS li 10 l VuSTfIeA1 WI TIO CA LIC# CLASS Alifoa <br /> INSURER 9WC. CoenG $Car cr 146vr&oCa FWP WORKER COMP# <br /> FIREDISTRICT ,Pt • n PERMIT# 9N,0,+v6 <br /> LABORATORYNAME Ip COUNTY v It, PHONE# <br /> SAMPLING FIRM PHONE # 14 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENTS PAST DATE INSTALLED <br /> 39- /O be0 �a gol, ritY vwL7 <br /> 39- ocO V ICu( <br /> LA k-YUMOA <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING 9 <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKERS COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING. 9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS <br /> /)OF�CALIFORNIA.'�}/�� <br /> APPLICANTS SIGNATURE TITLE/ C,U1- �Dp- nArl&J5t&ATE /1'26-02- <br /> ❑ <br /> APPROVED m APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> IS <br /> CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NA - M a ( DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046(REVISED 08113/99) Page 3 - <br />