Laserfiche WebLink
�ir,' Er,�yIRONMENTAL HEALTH DEPARTMENT <br /> a. NL SAN JOAQUIN COUNTY Jj <br /> Q <br /> LICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE <br /> (&REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT CL_A:�/y ap (yER? PHONE# <br /> FACILITY NAMEC/9L7R& yl� �F7 <br /> ADDRESS f� �y{� `So r-, "�,`��"' - rlja'O PHONE# ivq <br /> < !' OS F a 4 <br /> CROSS STREET <br /> OWNER OPERATOR -- <br /> PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME �j Pa^o o & A/sem{S �� PHONE* <br /> CONTRACTOR ADDRESS GD d'//��/ ���� get.) CA LIC# 71,60j-49 CLASS <br /> INSURER 7 Av <br /> g !2lS SWORKER COMP# UQ 33 7 <br /> FIRE DISTRICT +c%TGh Rin je Z PERMIT# <br /> LABORATORY NAME SSe 7 COI NTYL/If �Giyl <br /> SAMPLING FIRPHONE#JO 30 <br /> M /C�ilCd -/� �� p�pRDoyq PHONE# <br /> S` / <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAS <br /> 39-p DATE INSTALLED <br /> `'FO 3 010.0- cA/. lvl4S TF d 014 <br /> 39- Ora2c7 3 "e <br /> 39- 01320-4 k 3 Lc". �' ,r/G✓.4.r a�� <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDE�'��.�AWSftNO RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE'CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRINp-.OE_,55ll$ ONTRAGT,IN,G <br /> SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT E PERFORMANCE OF THE WORK FOR WHICH THIS' R)1�IT 19.j18 l)ED�1 CTING <br /> EMPLOY PERSONS SUBJECT TO WORKER'S CO OLA OF CALIFORNIA.' ... <br /> APPLICANT'S SIGNATURE <br /> - TITLE, �jzri✓Cr`✓/1ZDATE <br /> I' <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVID <br /> (SEE CONDIT ONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME_. ok,�oDATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WOR <br /> CONDITION <br /> _C��aC�ed Ova, �,��rCA Qu ck I -1 y -20l`5 <br /> EH 23 046 (Revised 07/17/14) 3 <br />