REMOVAL_2004 - Laserfiche WebLink

Home Browse Search

ENVIRONMENTAL HEALTH DEPARTMENT APPLICATION ' R UNDERGROUND STORAGE T/ f CLOSURE PERMIT THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# I PROJECT CONTACT { r hGf PHONE# 6 I a FACILITY NAME r' 0 PHONE#) 7� ADDRESS I el ff tV i CROSS STREET r OWNER OPERATOR PHONE# , I ZU CONTRACTOR INFORMATION CONTRACTOR NAME If r— w NC , PHONE# CONTRACTOR ADDRESS ' G CA LIC# 7 G CLASS+ . � INSURER f i ORKER COMP# lfz FIRE DISTRICT P it IV r f 1'?'>" PERMIT# Lr ! C L LABORATORY NAME COUNTY PHONE# SAMPLING FIRM &7L `I^ PHONE �i TANK INFORMATION TANKWfTANK SIZE TANK CONTENTS PRESENT& PAS DATEINSTALLED 39- 'b Ic 39- !I ` 39- 134144- 5 0 W10 39- 39- 39- r p K/ v C441APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, FEDERAL LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' `. APPLICANTS SIGNATURE s`— TITLE DATE ❑ APPROVED ❑APPROVED WITH CONDITION(S) ❑ DISAPPROVED iir (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME [_ 1{ - DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING_WORK. CONDITIONS: EH 23 046(REVISED 10/16;03) Page 3 1. (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES]] NO