Laserfiche WebLink
OWN <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />RGROUND <br />US <br />ANCE <br />TANK <br />APTHISAPERMITOEXPIRESN90TDAYS P FFROOMYTHE APPROVAL DATE. DOT NOT WRITE IN PLACE 1N ANY ESHADED AREAS. INDICATE <br />NDDICATETPPERMITTTTYPE <br />CLOSURE OR EBELOW: <br />a � mul rInSURE CLOSURE IN PLACE <br />EH 23 046 (Revised 7/10/92) .Page 3 - -- <br />EPA SITE #C1qCb00839q7& PROJECT CONTACT 8 TELEPHONE # - L <br />P ONE # <br />F <br />FACILITY NAME _. <br />A <br />�J <br />C <br />ADDRESS <br />I <br />L <br />CROSS STREET ,� 1 <br />1 <br />PRONE # <br />T <br />OWNER/OPERATOR <br />Y <br />r <br />�. <br />PHONE # <br />._7?5-7-2_ <br />C <br />CONTRACTOR NAME <br />O <br />CA LIC# Slj <br />CLASS <br />N <br />CONTRACTOR ADDRESS Vi <br />T <br />WORK.COMP.# <br />R <br />INSURER <br />ZAA <br />A <br />PERMIT # <br />C <br />FIRE DISTRICT L <br />T <br />PHONE # C� r, _ ��•Z_ �� <br />0 <br />LABORATORY NAME �. <br />R <br />PHONE # <br />SAMPLING FIRM ��(.44 Q� G I,C.lit.i5'SGC� — C <br />11111111111111111111111111h 11 <br />TANK SIZE CHEMICALS S10RED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />TANK ID # / i i �1i�GLr hi1,Ii k�IrY%'l <br />—' <br />39• <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39• j .( <br />P <br />APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />L <br />A (SEE Ai HMENT WITH CONDITIONS) DATE J <br />N PLAN REVIEWERS NAME Y�'�/p(7' y77 TnT�TTmTTTTTTTTTTTY"'II <br />�I �I �I �I �I ii �1 �1 �1 �1 X111 �1 �1 �1 �1 ii �1 �1 �F ���I �F <br />1111111111111111111�IIIIIIFF7F ���1�11� <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN J0AQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />FY T IN <br />I LICENSED A NATURE TPERSON IFIES T <br />JOAQUIN TY SUCHHE OAI KANNERI ASETOI BECOME <br />LIWORK E SMOT GEMPLOY <br />TSAN SMALL ANY IN <br />HE PERFORMANCENOF THE FORHWHICH THIS PER IT ISS ISSUED, I <br />WORKER'SWING: <br />HIRING <br />TOTHE <br />PERSONS SUBJECTCERTIFIES <br />EMPLOYSIGNATURE <br />SUJECT TOISSUED, SUBCONTRACTING <br />WRTHATE PPERFORMANCELAWS <br />CERTIFY INSTHE OF TTHEGWORK�FORAWHICHOTHISCPERMIT <br />COMPENSATION LAWS OF CAI <br />NIA. (� <br />��VII Pyne✓"'[ Qc^ i. <br />TITLE u' <br />APPLICANT'S SIGNATURE: -fTr <br />EH 23 046 (Revised 7/10/92) .Page 3 - -- <br />