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f k3:ti It t1w it:tv it:Vt:ff tit:trill:ft tt:ff it:Via tid ti,t i tl:it:ff it'ti ti tit {ail't1l. <br /> i ' kk� <br /> APPLICAM FOR PERMII i SAN JOAQUIN LOCAL HEALTH WICT �LAO <br /> UNDERWIND TANK 1 1601 E HAZELTON AVE., STOCKION CA Y: <br /> to CLOSURE OR ABANDONMENT Telephone (209) 468-3420 OPIX <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br /> REMOVAL ..... TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE I c sc r) i PROJECT CONTACT & TELEPHONE I <br /> A —�7— PHONE # <br /> F FACILITY NAME L)M E <br /> C ADDRESS 1, R4 <br /> I —� (0 u <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE 9 <br /> Y c( <br /> 0 <br /> C CONTRACTOR w ALT �\P, PHONE I -)t, <br /> u-- at !] gD561 <br /> N CONTRACTOR ADDRESS 0 �4 CA LIC t T3 D CLASS <br /> T + <br /> R INSURER WORK.COMP.1 <br /> A -S + ------ <br /> C FIRE DISTRICT PERMIT IIINSPTR <br /> T :�—ER� --- <br /> 0 LABORATORY NAME PHONE I <br /> R ENty, 993 13qD <br /> SAMPLING FIRM# SAMPLING METHOD <br /> mm —.-- ; 5 <br /> T TANK ID I TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSU <br /> A 39- P- <br /> _,23 /- _=ol <br /> N -------- - <br /> K 39- <br /> ---------------------------- <br /> 39 <br /> ----------------------------- <br /> --------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> ................ <br /> P APPROVED ___APPROVED W CONDITIONS DISAPPROVED <br /> �All IN <br /> L �(SEET CH WITH CONDITIONS) <br /> NDITIONS) <br /> A PLAN REVIEWERS NAME <br /> ----------------DATE <br /> N --- --------- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SULL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO DECOM <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED - DATE <br /> ----- -- --- ----- <br /> OFFIC-1--us-f-i-ML-Y--[H-23-046'12128--------------------------------------------------------- ------------I--------------- <br /> SWEEPS I I COMP # 1LOC CO E DIST CODE AMOUNT DUE I AMOUNT RCVO C N I RCVD BY I DATE <br /> Z/ i8 LM3 WCT-H <br />