COMPLIANCE INFO_1997-2006 - Laserfiche WebLink

Home Browse Search

2-26-1998 11.49AM R! Ll JOAQUINSAN r ENVIRONMENTAL f DIVISION • r �h&TotmR7ltJ^l, P. 3 THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE EPA SITE # / PROJECT CONTACT & TELEPHONE R�h J G fJ 1 f1 A F FACILITY NAMED®� PHONE A LF Eye C ADDRESS I L CROSS STREET c 1 ® � T OWNER/OPERATOR PHONE C CONTRACTOR NAME e PHON 0 N CONTRACTOR ADDRESS CA LIC # CLASS z T R INSURER WORK -COMP.# A C FIRE DISTRICTPERMIT 0 Tto 0 LABORATORY NAME e OUNTYPHONE R SAMPLING FIRM PHONE 4 111111111111111111111 11111111 TANK ID 7F TANK SIZE CHEMICALS ST ED CUR ENTLY/PRE OUSLY DATE UST INSTALLS T 39- A 39- N 39- K 39- 39- 39- P 1111! 1T 1 111 1 1111 II 111 1111 1111111 1111111111111 1 L APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED A (SEE CONDITIONS BELOW ANO/OR ON ATTACHMENT) N PLAN REVIEWER'S NAME DATE Illllllllllllllllllllllllllllltlllltllllll11111111111 11 Illllllllllllllllllllillllllllllltlllllllllllllllllllllillllllllll APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S 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: "I CERTIFY THAT IN THE PERFORMANCE OF THE gWORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CA C A.1° A APPLICANT'S SI CONDITION(S): Iq cicuste -— EH 23 046 (Revised 9/11/96) Page 3 TITLE -IDATE _