Laserfiche WebLink
r17 <br /> SAN J(-__ )UIN COUNTY PUBLIC HEALTH RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FRSTORAGE TANKO S)PEXP RES 90 DAERMANENT/TEYS OFROM THE APPROVAL DATED.ODO NOT RARY CLOSURE OR ABANNMENT IWRI ECNOANY SHADED AREAS. SUBSTANCES <br /> INDICATE PERMIT ES <br /> ❑ REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> 777 7TPROJECT CONTACT J '0 PHONE 3�� Z <br /> EPA SITE# PHONE#(Z O f 2 3Z- <br /> FACILITY NAME 12, <br /> ADDRESS G L p o Lv+9' LO CA . <br /> CROSS STREET Cz-oIF= 14vC 61E PHONE a <br /> OWNER OPERATOR <br /> p CONTRACTOR INFORMATION <br /> LFIRE <br /> TOR NAME S (� rd PHONE <br /> CTOR ADDRESS O KO COd CA LI # 7 CLASS <br /> G�YI Go ORER COMP# /SU / <br /> TRICTERMIT# <br /> ORY NAME GG /rVC . COUNTY V G FIRM PHONE jojJ - Su�/?i <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39-:0-1 3r a /0 00 0 / F <br /> 198.0 <br /> 39- <br /> po <br /> 39- D/ <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING. 'I <br /> 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 <br /> OBECOME FOLLLOWING SUBJECT <br /> ERTITHAWORKER'S CONTRACTOR'S <br /> IN THE PER OE W <br /> RMANCE OF THORK FOR WHICH THS PERMIT IIS ISSUED,I SHALL A <br /> CTING SIGNATURE CERTIFIES <br /> THE EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CA <br /> LIFORNIA.- <br /> APPLICANTS SIGNATURE TITLE ¢/^A <br /> X / w �m <br /> � ' � ATE / <br /> ❑ <br /> APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME r�f�/ / #I'`l � DATE <br /> ANY DEVIATIONS FROM THIS APPLJCATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> 57 <br /> _ 1 <br /> ,f/�/Q S. of Z <br /> S <br /> EH 23 046(REVISED 10/19/98) Page 3 <br />