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r Rfi'rfi'rfi kfi ;fi rfi rfit kfi kfi tfi tfi t3 kfi kt rfi rfi.rfi rfi kfi kfi tfi rh tfi rfi. <br /> APPL[CI,. OR PERMIT SAN JOAQUIN LOCAL HEALTH Dig <br /> g: <br /> UNDERGROUND ?ANI r: 1601 E HAIRLTON AVE:, STOCXTOI O <br /> 1 r: CLOSURE OR ABANDONMENT t: Telephone (204)' 168-3120 <br /> R: <br /> t�rfi�Zfi�R'R�ti:tfi=tfi�rt'ff.LI:kfi!v_l'tftti:L'fi-L`fi,tfi,L't:kYft"Rfi=ft.rfi ak_-VrtL'1'= <br /> � tfi,ft,k:r.rtrt,kfi: OCT 4 5 1989 <br /> APPLICATION FOR PERMANRNTITEMPORIRY CLOSUWE OR ABANDONMENT IN PLACE OF UNDERGROUND HA2IRDN99090if IGITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM TRE APPROVAL BITE. UO NOT WRITE IN IIT SHADI'D IREIS. INDLOY: <br /> REMOVAL _ TEMPORARY CLOSURE _ ABINDONNENT IN PLACE <br /> EPA SITE 14�� I� �gs�,lS PROJECT CONTICT S TELEPHONE I ��'4 `;'�"'l 14 f'�SJC <br /> F FACILITY NAME PHONE 11I J <br /> c ADDRESS I <br /> I I <br /> 1 L CROSS STREET <br /> 1 <br /> T OVNERIDPERATOR • PHONE 1 � <br /> s <br /> T F <br /> W i F_151C _ <br /> zd_ <br />' C CONTRACTOR MIME / — F ... ".._— PHONE <br /> � / cl �f � l�, EA3 _ <br /> II CONTRACTOR ADDRESS + �S` �S C1 LIC #, CLASS <br /> R INSURER L a 6tcrA'ccc C p VORK.COMP.1 <br /> CFIRE DISTRICT PERMIT I/[MSPTR <br />'I T S.4 .c; o R .'7 b5'S j( _ <br /> R LIB081TdRY NAME r,r 4 r l A/U (r6 M��7 4 PHONE I S O ���z Q 1� ( 4 <br /> SAMPLING PIRKt lam; t ! v I r d 0eN 7 AL SAMPLING METHOD <br /> IVtltltlit101tl030tllNtllltltlltlDWtlll0i8DRtltl0llU�tliUlO�iIWII�ItltlllBl <br />'F ?INK IO 1 TANK SIZE CHEMICILS STORED CORRENTL CHEMICALS STORED PREVIOUSL <br /> T <br /> aoo GAC LGa� <br /> : <br /> Y 34--w:7— _ _ AL uc — <br /> K <br /> 39- I } <br /> LIST ADDITIONAL TANK INFORMATION I'S NEEDED ON SEPARATE FORT[ <br /> 001006tlI1000tltlD0tlIDItl00�0fIUII10gIIWtlOUBul09YDutll uuOtl�VItl010tlNtlluuluuutl�luuDuuuulOtltltlWtllllll0d11lD0tlu10tlluut101Dtlluuuluuktiv0lWtllYuutllbtlquDlllllulutlluuu91Du0EWUIt101uutluutllDuuNl�fl011tl1i�01� a IHuuNUIu ' <br /> P x APPROVED APPROVED PITH CONDITIONS �I DISjIPPROVED <br /> L , ( 8 ITTACHMEET VI CONDITIONS]', ` <br /> I PLIN REVIEWERS MIMS DATE <br />� tl�ll[Id110�1NllD0011d1NtlI�tlIIINW0B0U�D11611UIlutltlllliDOItlDIDHlIW1101D@tlIWIi001m10gNWtlltltlllNtlltllltlBtll611ll INI1WItlllWitliltltltl'ILtl0iW01i0tlllODlitl�llllHltllllltll�IJI�tlSIIDIGLsI�'9"`� �i1I101fdR1Nf!IIY�IItlD6' <br /> IPPLICANT MUST PERFORM ILL YORK 11 ACCORDANCE WITH SIN JOIQUIM COUNTY ORDINANCES, STATE LAYS, IND RULES IND RECULITIOHS <br /> OF THE SIN JOAQUIN LOCAL HEILTH DISTRICT. OWNER OR LICENSED AGENT'S SICNITURR�'CEST[FI.,ES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY INY1 PERSON IN SUCH MINHER IS TO BECOH <br /> SUBJECT TO YORKER'S COMPEN * F , <br /> SATION GAYS OF CAL RN <br /> IFO II. CONTRACTOR'S HIRING OR SU CON <br /> � 0 TRAC?INC SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE <br /> Y68K F08 WHICH THIS PERMIT; 1S ISSUED, [ SMALL EMPLOY PERSONS SUBJEC <br /> TO YORKER'S COM <br /> PENSATION LAWS OF CIL FO <br /> I RkII. i <br /> I ,i <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN: ADVANCE <br /> r <br /> SIGNED_ �V�.ciccz�t —�1�' DATE 1(J 5^ Ff`( <br /> c <br /> OFFICE USE ONLY--Ell 23 046 rr1 cp2111p cccc h r@ phr Fc pr {—�r r' r cc rT rc "rpp c t r ((p r--(--r--- <br /> Y��iiir���iiYY9�ii����iJ��i�YiSSiV�VfSSSS�$$�$��5�$S$$$S$S#$S$SS3S�$���$�$Ss$$s$�$$s$ss SI�iSSSSSS S�V�$fSSYSS9Si4SSS:S�CSISaSS � <br /> SWEEPS # COMP I LOC CODE DIST COBBAMOUNT DUR AMOUNT RCVD CKI/CASH RCVD' BY DATE RCVD PERMIT # <br />