REMOVAL TEMP CLOSURE 1998 - Laserfiche WebLink

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SAN JC.)UIN COUNTY PUBLIC HEALTH `?VICES ENVIRONMENTAL HEALTH DIVISION 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: ❑ REMOVAL TEMPORARY CLOSURE ❑ CLOSURE IN PLACE TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- 39- 39- 39- 139- 139-- APPLICANT 9-39-39- 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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WCjRK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOF y(ER'S COMlfENSAjION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFYL-�q I��ERFO NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION WS CAL, ORNIA APPLICANTS SIGNATURE ❑ APPROVED VAPPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) if - ANY PLAN REVIEWER'S NAME��Cl/� DATE IuZ�- DEVIATIONS FROM THIS APPLICATION MUS B SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDIT ONS: / t v'G T i EH 23 046 (REVISED 10/19/98) Page 3 FACILITY INFORMATION EPA SITE # PROJECT CONTACT PHONE v-5(6 FACILITY NAME �G1C.. PHONE #ZaY-1�3I-6 ADDRESS 6too WORKER COMP# Z - CR S STREET {-n PERMIT # OWNER PERA OR I PHONE#Q 77 — TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- 39- 39- 39- 139- 139-- APPLICANT 9-39-39- 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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WCjRK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOF y(ER'S COMlfENSAjION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFYL-�q I��ERFO NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION WS CAL, ORNIA APPLICANTS SIGNATURE ❑ APPROVED VAPPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) if - ANY PLAN REVIEWER'S NAME��Cl/� DATE IuZ�- DEVIATIONS FROM THIS APPLICATION MUS B SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDIT ONS: / t v'G T i EH 23 046 (REVISED 10/19/98) Page 3 CONTRACTOR INFORMATION CONTRACTOR NAME -<'r0 S _ PHONE # j .T -3 d CONTRACTOR ADDRESS CA LIC # ` O CLASS"44 JVM INSURER WORKER COMP# Z - FIRE DISTRICT {-n PERMIT # LABORATORY NAME COUNTY l 3.PHONE # SAMPLING FIRM PHONE It TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- 39- 39- 39- 139- 139-- APPLICANT 9-39-39- 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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WCjRK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOF y(ER'S COMlfENSAjION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFYL-�q I��ERFO NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION WS CAL, ORNIA APPLICANTS SIGNATURE ❑ APPROVED VAPPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) if - ANY PLAN REVIEWER'S NAME��Cl/� DATE IuZ�- DEVIATIONS FROM THIS APPLICATION MUS B SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDIT ONS: / t v'G T i EH 23 046 (REVISED 10/19/98) Page 3