Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> RGRaJND <br /> ANCE <br /> TANK <br /> APPLICTION FR <br /> TDAYSP FROM YTHE APPROVAL DATE. 00TNOT WRITE {lif PLACE DN AMY ESHADED AREAS.D IINJDICATETPERMIT STORAGE <br /> CLOSURE OR TYPE BELOW. <br /> V REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE UP,)57✓4 <br /> /;- <br /> EPA SITE �q G(gjy(�'J7jQCJFj PROJECT CONTACT i TELEPHONE i (� <br /> F FACILITY NAME 9--rt/Ab5W- i, eA�-LY(,-o(�j'(� L 9 PHONE Z9(7 If q5l' 9" <br /> A ADDRESS V�'Of /At4 ©lS/��1KI qtL Druvf <br /> CRcSS STREET <br /> I PHO(E 9 <br /> r OWNER/cPERATOR T /'Wol LM z7—i.A!Cr <br /> j r 1ANT-(NYNTf� (� l ri TMSt(tl! l W <br /> r l SE/�1�D PHONE Y X09 mss! g6S.3 <br /> CONTRACTOR NAME G <br /> ccA LIC -4 5 �'9g6� CLASS ";/Is, C6//OHO <br /> v C.NTRACicR ACORESS /Z/� Sc�T.N 7� /yloDeSTO _ <br /> I i (la oEA! �f}6L� NSGI��}UL� CAO, LnRK.ccHP.. <br /> INSURE_.: �OI(fG L4�S�Caj'� <br /> j A PERMIT gs-/2 9 <br /> I I F RE DISTRIC" (•ry (/Y Sf�F <br /> — 6'eoA��a�yTi<<re LAZ�e97oeiFf PHONE k Za9 SQL 6900 <br /> a6cRa7cRY NA-4E <br /> PHONE s <br /> SAMPL'-NG FIRM ZO9 5�Z 0900 <br /> II(IIIIIIIIIIIIIIIilllllllllll TANK I/nZZE� c IULs STORED CURRENTLY/PREVIOUSLY DATE UST IHS7ALLE0 <br /> TANK l0 �I✓yV �MV _lJ' Ot lud- ���( , <br /> I 39- <br /> 39- I <br /> 1 3;- <br /> < 39- <br /> 39 <br /> 39• <br /> Illllililliilllllllillllllilll III III Illl Illllllll II III Il II IIII Illll II llltll Illlllllil IIIIIIII IIIIIIIIIIII <br /> — <br /> � APPROVED �APPROYED WITH COND(TICN(S) Of SAPPROVEO <br /> a (SEE-- ATTACHMENT WITH CONDITIONS) <br /> N PLAN RE'/IEW'ERS NAME DATE <br /> IIIIIIIIIIIIIIIIIIIi 11111 <br /> I <br /> APPLICANT MUST PERFCRM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANO REGULATIONS OF <br /> SAN JOACUIN COUNTY PUSLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "t CERTIFY THAT IN <br /> THE PERFORMANCE OF THE LURK FOR ICN THI5 PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SU6JE^, TO t:CRKER'S CCMPENSATIC LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCOHTRAC7ING SIGNATURE CERTIf[ES THE FOLLCWfNG: <br /> "i CERTIFY THAT IN THE PERFORM CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> j CC•MPENSAT:CN LAWS OF CALL <br /> APPLICANT'S SIGNATURE: <br /> TITLE � '�r1 • +"' r, DATE 1 S <br /> Lid (sa.^M -�;6c� <br /> �bLl lA� .' p <br /> .+ 23 OGc _ (Revised 7/1 /92) Pa 3 <br /> 4� P4-5 - t�(D u3/( L So da q s d0 n-e�Jma0c,� <br />