Laserfiche WebLink
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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> CV,_ REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE #S G� PROJECT CONTACT & TELEPHONE # ;77Ul �arrGtt Call&) &31 -7-71 ) <br /> F FACILITY NAME CJ- OLrthlard 7_cLoveI'l St'ora4Zo1v32 PHONE # <br /> A <br /> C ADDRESS 1&27 02Vinci Dr eve, <br /> I <br /> L CROSS STREET parch Lane, <br /> I <br /> Y OWNER/OPERATOR -r�Q � �.1_'ana �ra�IL`n PHONE # <br /> rIG U,►i <br /> ('11&) &31 -7711 <br /> C CONTRACTOR NAME Nla►tiett? PHONE # (5&Z) 5145-4555 <br /> 0 <br /> N CONTRACTOR ADDRESS 1t�I �, S�Ify� 5tre t, Long d h CA LIC # 55�p33 CLASS A, E5• HAM' e>' <br /> T GIZ r-zI 6Z7 4-6? <br /> R INSURER NaI. Union Fire Ins. Go, I WORK.COMP.# WG8J7�to3�D <br /> A <br /> C FIRE DISTRICT I PERMIT # <br /> T <br /> 0 LABORATORY NAME Wes,' Laboraj'crjesCOUNTY 'yoiQ PHONE # I(o <br /> R I t� 7S7-(J=iZrJ <br /> SAMPLING FIRM P1U0r - 02rlielt� (7T1 PHONE #(LIZ5) 370-3-1`10 <br /> Itflllllll11111111111111f11if1 <br /> 39- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- — IO,00o �R gu-ar Unitad <br /> A 39- --O I014yo ( e- „ adk a <br /> N 39- P-hey"fum Unk tb d tg74 <br /> K 39- <br /> 39- <br /> 39- <br /> P 111111111111111111 ft 11111 I I illf I 1 1 III 1 1!111 II III11 1 iil lllllllllilf111! <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N G D <br /> PLAN REVIEWER'S NAME I�' r':c✓/1�.�--� DATE <br /> 111111111i1i11111111fllllllllllllllllllillllilllfllllillllllllfill!!tltllfllllltlitl1111t11111IIIIIIIIItIIlIIf111111111111111 <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: 18I 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 FOLLOWING: <br /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE "`7 CCiI QHL. n TITLE Arlt fvr �C111Iti1 DATE 'Q" 15 MI6 <br /> CONDITION(S): �Z_S <br /> (fovn�,c- <br /> ,�d— fx- a GG.�.�•.o� i� �+� !v. cs�saw-�-� <br /> EH 23 046 (Revised 9/11/940; �� �{ �1r� 0Age 3 /O U " '� <br />