Laserfiche WebLink
t <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLCSAtE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM TROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA $ITE #GsAGD S+-O��Q� PROJECT CONTACT i TELEPHONE I M� • 5�; <br /> F FACILITY NAME J P l v PHONE / - <br /> A p`� <br /> 1 ADDRESS 3207 c�V 7 <br /> L CROSS STREET t <br /> 1 <br /> T OWN PERA�S <br /> T IR/ ^ PHONE 9 <br /> -'� � .., <br /> C0 CONTRACTOR NAME�7 C _ L' PHONE /PT <br /> N CONTRACTOR ADDRESS�ZC) v_ n <br /> < �"�' SllV. CA LICK 7Cr CLASS <br /> T J <br /> R INSURER — t� n L C. WORK.CCM{P.A��' / <br /> A C <br /> C FIRE D(STRICTC C'`C - Ft r-C — PERMIT it <br /> T <br /> 0 LABORATORY NAM C ' '?.i- PHONELL <br /> j <br /> SAMPLING FIRM PHONE 0 <br /> tllittl[Iltlltitll�llltllti111 <br /> TANK 10 TANK SUE LS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- In6 6- - 1 �•C�Oc7 I.V J:t s'� 9�6 <br /> T 39- <br /> A 39- Ga L C <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> - lilt <br /> P <br /> L APPROVE APPROVED WITH .COMDITION(S) DISAPPROVED <br /> A Isu HT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME -�� �'d' DATE <br /> I l t 1 t i l i t l l t 11111111 [I IIITiTITiTiTIITiTII M I l l 11 1111111111MITIMmu <br /> APPLICANT }BAST PERFORM ALL WORK IN ACCCRAAMCE WITH SAM JOAOUIM COUNTY ORDINAMC£S, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICFS./'OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN' <br /> THE PERFORMANCE OF THE WORK FOR WHICH Till PERMIT-IS- ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS rTMNIE <br /> J611 FORNIA." CONTRACTOR't HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> °1 CERTIFY THAT•IN THE PE fORl4AMCE OF K FOR WHICH THIS PERMIT IS ISSUED, i SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS Of CAL ORNIA.• <br /> APPLICANT'S SIGNATURE: ~ TITLE CDATE/' �j? <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />