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` -.--^- --„• ,,.. F IDUL c MULLIUM Aft., SIUCKIUN CAK `/Lt <br /> CLOSURE OR ABANDONMENT Tele hone (209) 168-319A <br /> PAYMENT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE fACILITYE D <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TVW”: j() <br /> JU <br /> REMOVAL ----- TEMPORARY CLOSURE ---- ABANDONMENT IN PLACE ENVIRONMENTEgLT ? <br /> EPA SITE 1^ PROJECT CONTACT 1 TELEPHONE 1 �jCt4,4�P-u h1AW7&F45ZFVf F� <br /> F FACILITY NAME PHONE 1 <br /> A 4 '1h-21 q <br /> C ADDRESS <br /> I ti T - TAn/k- 5i7� - V09 s , cAL1: czA,y, <br /> L CROSS STREET <br /> I 0� <br /> T OWNER/OPERATOR PHONE 1 <br /> Y RA MALAAJ 9r17-21 #7/7 <br /> C CONTRACTOR NAME PINK 11 34R <br /> Z4-9io53 <br /> T CONTRACTOR ADDRESS y31 W. Nom lac ibkG o CA LIC <br /> tyywi,y CLASS <br /> A INSURER \ ` WORK.0MID.1 pper�/� dd <br /> _ K��SJFD <br /> C FIRE DISTRICT <br /> T C T 6Tv-t4 PERMIT 1/INSPTR <br /> 0 LABORATORY NAME�� WA-T6k PHONE t <br /> R <br /> SAMPLING fIRMi S4N16 SAMPLING METHOD.- TF-PH <br /> TANK ID 1 TANK SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> A <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- -�.------------------- <br /> ------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P MOP <br /> ._ APPROVED ---APPROVED WITH CONDITIONS ___ u <br /> L (SEE ATTACHMENT WITH CONDITIONS) DISAPPROVED <br /> A PLAN REVIEWERS NAME <br /> H - DATE 16 -2 - <br /> � ------- ---- ----- - --- --- - ------------ ---- <br /> APPLICANT <br /> -------------- <br /> APPLICANT MUST PERFORM ALL WORK IM ACCORDANCE WITH SAN <br /> Of THE SAN JOADJOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> UIN 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 1S ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SUBCONTRACTING S16MTURE 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 <br /> OffltE USE 0 (Y--EY 1J 016 11/1lrV� DATE, - 2$-ice/ <br /> mossmum, <br /> SWEEPS 1 COMP / I LOC CODE I DIST CODEJ AMOUNT DUE AMOUNT RCVD CK11CASN000fOpCVtffBYf00fOfSSATE <br /> 0oil <br /> tffffftPt1„;Tt;lf <br />