REMOVAL_2007 - Laserfiche WebLink

Home Browse Search

ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY APPLICATION FOR UNDERGROUND STORAGE TANK 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: NI REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPASITE# AC.00Z(.Ir31 PROJECTCONTACT WIC644" WALf-oa PHONE# 916 - 3}3 - Irra- FACILITY NAME O (:—'S -1- V F-L L A A PHONE# O 9 - 2 a S- 2 40 P ADDRESS 1 5-600 S , L A-VA (211 . CROSS STREET FF 0 A.v 6-4 '2.O OWNER OPERATOR O L Uj t'L - 0 PHONE# O 5 - 2 )-r- 2 :�0 CONTRACTOR INFORMATION CONTRACTOR NAME L-1-04 SAC( IALGefZ46C f. PHONE# 16 . 333 - /t S. CONTRACTOR ADDRESS 'P.0,6OK t0air . Sblt0 CA 9S-641 CA LIC# t�7°3F CLASS B aA2- INSURER T Nt"E Pa" WORKER COMP# 413 000 Y y 2 3L0 6 FIRE DISTRICT C L. O F L A-rN ILO P PERMIT# LABORATORYNAME STL SA.t FM1tMCt9Co COUNTY o�A C01rhl PHONE# Oat- rY- 19t4 SAMPLING FIRM I V $-b+(- GetNt 0 r EO L PHONE# a r- 1,45 - i t t TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED 39-05 I s 1 S-00 NL r-p- • 19 r 0 Z 39-b S-00 A4 rL� • lar 0 39- 39- 39- 39- APPLICANT 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 AGENT'S 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�ERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S C MPENSATION LAWSSOJJ CALIFORNIA." APPLICANT'S SIGNATURE / 1 TITLE r&+`L --rZ AdJCb h DATE 6 O ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAMET //Js+°.ly�� 't DATE q ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 11/21/06) i