Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVlRON7VfENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PER-NUT <br /> HAZARDOUSACE OF UNDERGROUND <br /> iRMl7 FIPfROMNENT IHE/APPROVALYDATE. 00 NOTBWRDITEIN <br /> MTAIN PL <br /> NY SHADED AREAS, I NDICATEPESUBSTANCE STORAGE IAN <br /> RMITPE3ELOW: <br /> i <br />:S90DAS <br /> REMOVAL TEMPORARY CLOSURE CLCSL'RE IN PLACE } <br /> --� <br /> PROJECT CONTACT & TELEPHONE 9 Ij M � oll <br /> SITE C d Zr3 Sr ?HONE = y� <br /> Z <br /> ILITY NAME E; <br /> RESS 2 { <br /> a A <br /> SS STREET L74GE <br /> Aa 1 <br /> PHONE ; <br /> ER/OPERATOR �' Dam �o E <br /> �o9 -� � - y�35 <br /> r i PHONE = 2`J - O <br /> ITRACTOR NAME <br /> r <br /> CA LIC �$0_L CLASS <br />(TRACTOR ADDRESS (� A S� <br /> �} -C MP..g 131 7 <br /> � WORK <br /> -95 <br /> SURER .f !� uro , L SS 9Ci 4,r2. <br /> PERMIT <br /> RE DI.STZICII"Inn -C2v�A £ D ,;* <br /> COUNTY µE C' I PHONE <br /> BORATCRY NAME AI �� (� UU <br /> PHONE <br /> MMA <br /> 4�y-{ icy <br /> ll1�11 h TANK SIZE CHEMICALS STORED LM;RRE4TLY/?REVIOUSLY DATE UST INSTALLED <br /> rU4 <br /> i- lllllll 1111!! <br /> llllllllllll111111lllllllllllt{1111111lkllllll{Illllll{Illllllllll�lllkllllill{Illllllli <br /> APPROVED <br /> APPROVED WITH CONDITION(S) DISAPPROVED <br /> -� XE� CONDITIONS "sELCW AND/OR ON ATTACHMENT) 7CA <br /> �SATE <br /> LAN .REVIEWER'SNAME <br /> {11i111111 full{,SCANT FEUST PERFORM SIGNATURESCERTIFEEESA�THE FOLLND UL <br /> RTIFYTI OTBANS OT INJOAOUIN CW HE FO <br /> PERFORMANCE OF THE WORK FOR WHECH THIS PERMIT 15 155UED, 1 SHALT NOT EMPLOY ANY PERSON iNSUCHTIF TQ BECOMEIECT TO WORKER'STHCMPENSATMANCEAQF 0THEWORKOFORAWHICHOTHISC?SrTMITHISIISSUED, I SHALLOR CEMPLOY1PENG GNATURE TOTWORKER'SWIHG::ERTIFY tHAT IN IEHSATION LAWS OF CALIFFO�RNIA." G1TITLE SRF 4r. � - -- ED' y� <br /> LICANT'S SIGNATURE: <br />)M.ON(S): <br /> G +" <br /> Paye 3 <br /> 23 046 (Revised 9/11/96) <br />