Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE 1N ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE # Ch(- 000 (Oqo y PROJECT CONTACT 8 TELEPHONE �6 / all <br /> F FACILITY NAME LO�4Ere9eD 1414kT //�R� ���LS (�JEU�E �[ PHONE %�Y,:?2,7 ^ 7/LOS <br /> A <br /> C ADDRESS <br /> 1 <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> C CONTRACTOR NAME PHONE G✓^C �'' L �� <br /> 0 <br /> N CONTRACTOR ADDRESS yr3/ k),1/47-cH 2,�) I)�STQ CA LIC # // �/� CLASS <br /> T <br /> R INSURER T/G(�v �j��2��� WORK.COMP.# 0-L <br /> A �/ 4 <br /> C FIRE DISTRICT �Q�E�(,��(f�� ��2� D�i��27- jj� PERMIT # <br /> T <br /> 0 LABORATORY NAME �(CO�tiALy�/(�L PHONE #Z,5? , 5?2-,N00 <br /> R <br /> SAMPLING FIRM �'J�O�����r/C� (� PHONE # <br /> III II III II III II II III II III II III <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- �q LGo �l So�tiE LFsI��� <br /> A 39- 6,4e-e-6,vZ7/CbS�L /9� <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P Illilllllllllllllillilllllllllllllilllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll <br /> L APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED <br /> A c(SEE ATTACHMENT WITH CONDITIONS) J <br /> N PLAN REVIEWERS NAME �/ I J`- V(*� _ DATE <br /> IIIIIIIIIIIIIII IlillllllllllllllillllllllllllllllllllllllllillllllllllllllllllllllllllllilllllllllllllllllllllllllllllllllIII <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 FOLLOWING: <br /> "I 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: `/& <br /> Zy TITLE �a2�u/ DATE �Q 11 <br /> EH 23 046 (Rev 2/8/91) ft Page 3 <br />