REMOVAL_2004 - Laserfiche WebLink

Home Browse Search

*ENVIRONMENTAL HEALTH DEPAWENT APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTlrEMPORARY 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 FACILITY INFORMATION EPA SITE# PROJECT CONTACT O✓f A t PHONE# -Fj FACILITY NAME 0f4Ajq,4 ADDRESS E —76 CROSS STREET G4,1w OWNEROPERATOR PHONE# Q CONTRACTOR INFORMATION CONTRACTOR NAME PHONE#,20 , CONTRACTOR ADDRESS }p (,C CA LIC# CLASS INSURER WORKER COMP# - Q ' FIRE DISTRICT PERMIT# LABORATORY NAME b V(? A ICA(, COUNTY .$OaVGM,1tPHONE# �' SAMPLING FIRM PHONE # TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED 39 0 w O�v L 5 4 a 39- 7301 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 AGENTS 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: " FY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TOW ER'S COMPE TIO W OFCALIFORNIA.' l APPLICANT'S SIGNATURE TITLE \t DATE 12-`7"0 ❑ APPROVED EtAPPROVED WITH CONDMON(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE � \lo OA ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046(REVISEDI O/16/03) Page 3 1. (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES[] NO[]