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Camrt :akmlfikV kY aaaaL'rk?V tfi�tt�lfi�tfi�kfi�l'fi:tfi:tt�ti:t L'fi:ti:lfi: <br /> e aPP61CAtI0N FOR PERMIT !: SAN JOIOUIM LOCAL HEALTH ISTRICTt: <br /> t: UNDERGROUND TANK t: 1601 B HAZELTON AVE., STOCKTON Cat. <br /> t: CLOSURE OR 111NDOMMENT a Telephone (109) 168-3120 s <br />, !�tfi�kfi�tfi�L'fi�bk�tfi�kfi�lfi'!Y tlfifi�lt�tfi�kfi�kfi�kfi�tY l'fi tfi�Cfi�tfi�kfi'tfi�lfi�lfi�tfi�lfi�lfi�kfi�kfi�kfi�lfi�kfi� <br /> APPLICATION FOR PERMANENT/TEMPORIRY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT 11116 IN 111 SHADED AREAS. INDICATE PERMIT TYPE BBLON: <br /> REMOVAL --_ TEMPORARY CLOSURE — ABANDONMENT IN PLACE <br /> BPA SITE 1 C ACcr)c),X q y ci PROJECT COMTICT I TELEPHONE I C)q q6 , `aOZi j <br /> F FACILITY NAME 7 <br /> I trl, «\FcPHONE I T:nO, 9� ,&-, <br /> C ADDRESS i I (l7, l�1,1 'or> > - S �t,� -�C �c�r� r CIS <br /> I — — <br /> L CROSS STREET �lC� l\_J(��j <br /> T OWNER/OPERATOR �yA PHONE I \ <br /> C CONTRICtOB M►ME - I -__._------- -- PHONE I--------'-__.._ <br /> 0 c <br /> T CONTRACTOR ADDRESS � �� a ICA LIC 1 <br /> R INSURER 1 d YORK.COMP.I <br /> C FIRE DISTRICT � IAC\ — PERMIT 1/IMSPTR <br /> T ---- ( I 1I 1 1 — <br /> 0 LABORATORY NANB CC, 1 , 1 alc I. a l)� PNONB I �a 7 ' L'�r� <br /> SAMPLING FIRM' P f h5 SAMPLING METHOD <br /> — WWp3YWWWIWRYOWWlNWItlHIWW N1101111110Wawl -------- --- -- <br /> TANK ID I TANK SIZE CHEMIIC�ILS STORED CL'RRENTL CHEMICALS STORED PRE'1IOUSL <br /> 1 39- <br /> K 39- <br /> 39-- <br /> LIST <br /> 9 39- LIST ADDITIONAL TANK INFORMATION IS NEEDED ON SEPARATE PORN <br /> WIVNWWIIW4'WYIWRIHWWWIIIWOIWWYIIUtltlWUWWItlgWtltlURlgtl. OWHtlIOgtlWIiWIWW11111111011' WIWIUIIIWIIi!WUUIIItlWUUWtltlUUIWIOUISIItlAVIiIUWWWYV'UWtlWJIIWWPItlUGIdIUtWkJIWUNuyNNllUUIUWWIWIUWWWYIIWUWRItltlIIWtlWIUIIIIUWRIIHWWIIWW:' <br /> P —__ APPROVED �APPROVED PITH CONDITIONS DISAPPROVED <br /> L -- {SHB ATTA - MT YIT CORDITIONS) <br /> 1 PLAN REVIEWERS NINE <br /> M T <br /> gNYkWI k 6WWYWWIRMHIWWIWWVYYONMVtlYWW1WYIW�YIIRNBNWWRWWIOWWYYtltl <br /> APPLICANT MUST PERFORM ILL WORK 11 ACCORDANCE WITH SIN JOAQUIN COUNTY ORDINANCES, STATE LAYS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAOUIM LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 21 CERTIFY THAT <br /> IN TNR PERFORMANCE OF THE VORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER IS TO BECOM <br /> SUBJECT TO YORKER'S COMPENSATION LIPS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 81 CERTIFY THAT IN THE PERFORMANCE OF 1116 YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO YORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 40 HOURS IN ADVANCE <br /> SIGNED _`�iC�`1= -------------- DATES <br /> OFFICB USE ONL - II 13 016 11/11 <br /> SSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS-f-'-COMP_I-- 60C CODE-I_DISt CODE' AMOUNT DUE-�--AMOUNT-RCVD- I -'CKIICASH-I- -RCTD BY--I--DATE RCVD- PERMIT 1 - <br />