Laserfiche WebLink
i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # LOO PROJECT CONTACT & TELEPHONE # � ` <br /> F FACILITY NAME PHONE # o ?- 3 ,rj <br /> 1 ADDRESS Jo <-C:N.- <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # _ <br /> YC <br /> C CONTRACTOR NAME _ sr PHONE # <br /> 0 KL-. p 1 <br /> T CONTRACTOR ADDRESS #CA LIC CLASS <br /> R INSURER I WDRK.COMP <br /> A <br /> C FIRE DISTRICTPERMIT <br /> T off_ <br /> 0 LABORATORY NAME i COUNTY PHONE # <br /> • iSAMPLING FIRMc.� UL1 p������; PHONE # �_ 6-_ <br /> I.lIIIIIlII!l111ilIt1 1 1 1 1 1 i - SCJ � v�c,. i o (7 O r <br /> TANK ID # TANK SIZE CHEMICAt; STORED CURRENTLY/PREVIOUSLY ' E UST INSTALLEC <br /> 39 7. -G l CS q (a^�r�l-% y-, e <br /> 39 -A 39- 7. - - ' <br /> N 39- S_e <br /> K 39- <br /> 39- <br /> 39- <br /> P Ili[1 ! IIIIIliilll!!! II II lyllll I 7APPROVED <br /> L APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N �� �� <br /> PLAN REVIEWER'S NAME DATE <br /> 111I1111lIIIIII11ii1111!!!lII11111111l11111111llllllillllil1111111lIIIIIIIIIIIiIIIl1111111III11llllllillllllillilllllllllll? <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWIN( <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK -OR WHfCH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI . ' <br /> APPLICANT'S SIGNATURE: •L ^a Q <br /> TITLE « t DATE <br /> CONDMON(S): f f <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />