Laserfiche WebLink
_ 0 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> OUS <br /> ANCE <br /> TANK <br /> APPLICATION THISPERMITOEXPIRE N190DAYS FRCMYTHE APPROVALABANDONMENT IN PLACE DATE. DO NOT WRITE OIN ANY SHADEDDARE S. INDICATE PERMITSTORAGE <br /> TYPE BELOW: <br /> REMO'!AL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE xc p L o00l0 0 0 4 a <br /> PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAMECCI.GO/} .�,f'a:Yon / PHONE <br /> C ADDRESS a 3 S Q w U i C'r 00 �. <br /> I <br /> L CROSS STREET ,5 I C r r a. 1' GI yl <br /> I PHCNE x <br /> T OWNER/CPERATCRr V <br /> G <br /> Y UI+rtt. V`%ct 12 1 �ao4) 583 - Ss 9a <br /> C CCNTRACTCR NAME Wal+oY\ E�n a ' rCGY'in?i =NG. ( PHONE #L� /6, 3M -1 - 1985 <br /> O <br /> N CONTRACTOR ADDRESS P.�, bo a - ,�, Sac. C� Rs69t A LIc # / �� 3 gCLASSg / T <br /> INSURER WCzx.ccMP.# UC� oal a9aoSCb� <br /> UF\•I 2 Rcmovc — 140T3 <br /> A `I PERMIT x <br /> c FIRE DISTRICT GT GL. <br /> T 1 y� <br /> 0 LABORATORY NAME �G 4/vd , I T1" JI — C. Lit S PHONE # <br /> R I PHONE #(y/�> y3 9— 3SSo <br /> SAMPLING FIRM Wan /NI C l< C /SG�'1 , 1/bN ed W\1111111111111'"'�" �"I TANK SIZE CHEMICALS STORED CURRENT44Y/PREVICUSLY DATE UST INSTALLED <br /> TANK Ip # GntolinG UYl� <br /> 39. L <br /> T 39- <br /> A 39- q <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- T <br /> 1111 - <br /> P <br /> L _ APPROVED APPROVED WITH CONDITION(S) _ $APPROVED <br /> (SEE H <br /> A ATTACMENT WITH CONDITIONS) - DATE <br /> H PLAN REVIEWERS NAME - IM <br /> - 11111 <br /> 11111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAM JOAQUIN COUNTY ORDINANCES, STATE LAYS, AND RULES AND REGULATIONS OF <br /> TSAN HE PERFORMANCE OF F PUBLIC <br /> IWORK£FORNWHICflI HIS PERMITOWNER <br /> ISS Iss=,D IASHALLSNOTGNATURE EMPLOY ANYTIFIES PERSONTHE IN SUCH AI MANNER(ASToFY BECOME <br /> IN <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.• <br /> l l C�/� v TITLE DATE OCT 3 <br /> APPLICANT'S SIGNATURE. - - <br /> V, <br /> EH 23 046 (Revised 7/10/92) C - Page 3 <br /> • t <br /> 't <br />