Laserfiche WebLink
SAN J l QUIN COUNTY PUBLIC HEALTH RVICES <br /> ENVIRONMENTAL HEALTH DIVISIGN <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> AWREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE #CAG 0023S33S PROJECT CONTACT Kr,, r('OF-a& I PHONE# ZOq -q6> / 9333 <br /> FACILITY NAME - 441 ( _�/ EaES T- �''=„'�� E4K' 'c6F-2 I PHONE XZCQ- 956 -%O/O <br /> ADDRESS S lel o - qanaP,, <br /> CROSS STREET y - <br /> OWNER OPERATOR \ Ge - O PHONE <br /> CONTRAIC TOR INFORMATION <br /> CONTRACTOR NAME , �o. /lcc S7-r to-o iF€ CmI PHONE # Z49' S�6S��S � 33 <br /> CONTRACTOR ADDRESS yI o . AImAl �- ` CA LIC # 0S// OI CLASS mob / O <br /> ',NSURER A rr C.E)rA . DF112 WORKER CCMP# BO/(t � Z- <br /> FIRE DISTRICT GL PERMIT # <br /> LABORATORY NAME COUNTY L FM PHONE # S140 �9?9 /Z ZO <br /> SAMPLING FIRM - p�G Ep �( kwwr2l PHONE Y <br /> TANK INFORMATION <br /> TANK 10 # TANK SIZE TANK CONTENTS (PRESENT 3 PAST) DATE iNSTALL ED <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT <br /> 939-APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE 'MTH SAN JOAQUIN COUNTY ORDINANCES, STAi e LAWS, FEDERAL LAWS, AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 41 <br /> 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 <br /> TO BECOME SUBJECT TO WORKER'SC MPENSATION LAWS OF CALIFORN W.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: Al CERTIFY THAT IN E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPE. W IPCRN <br /> APPLICANTS SIGNATUR TITLE�t 1 %A7,�4E�A' DATE 3 59 -b l <br /> Cl APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (S�QEE CONDITIONS <br /> //B77ELO��W ANOlCR ON ATTACHMENT) �'-'� �. /� <br /> PLAN REVIEWER'S NAME / / 1 / � K� �C lf"L!V/ OATE,3 ✓ <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS : <br /> l i <br /> f C j <br /> I Lo <br /> y . aS- <br /> EH <3 Dab lREV E 10/ 199 ) Page 3 <br /> X <br />