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eIt:t;n:aitIt:It IV tl:at;�tYtyIT tvamattm. <br /> f APPLt-TION FOR PERMIT t: SAN JOAQUIN LOCAL HEALT" DISTRICT p��f <br /> t: Uri GROUND TANY t ""' E HAZELTON AVE., ,.,KTON CAp {� 60 <br /> G CLOSURE OR ABANDONMENT G Telephone (209) 460-3420 t, ?�2� 6P <br /> ff...i.". <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> TH11 PERMIT E111RES 90 DAYS FROM THE APPROVAL DATE, 10 NOT WRITE IN ANY HARD AREAS, INDICATE PERMIT TYPE BELOW: <br /> - # REMOVAL TEMPORARY CLOSURE ABANDONMENT 1N PLACE <br /> EPA SITE 1 3600 W �Can(a�s) d PROJECT CONTACT i TELEPHONE 1209 835 2293 <br /> Wend <br /> F FACILITY NAME Pescadero Reclamation Dist PHONE 1 same as above <br /> A <br /> C ADDRESS 3650 W Canal Blvd Tracy ( Banta) CA 95376 <br /> 1 <br /> L CROSS STREET mile East of California Ave . <br /> I <br /> T OWNER/OPERATOR Pescadero Reclamation District PHONE / 209 835 2293 <br /> Y <br /> C CONTRACTOR NAME �CfYI PHONE 1 <br /> 0 <br /> N CONTRACTOR ADDRESS 3 ee CA LIC t O CLASS <br /> T 5ior_kAon CA GS�r <br /> R INSURER WORK.COMP.t <br /> A -- -- -- <br /> C FIRE DISTRICT Banta Rural FirePERMIT t/INSPTR <br /> T <br /> 0 LABORATORY NAME pa-1 0s-0 PHONE ! <br /> R California Water Labs . <br /> SAMPLING FIRM# SAMPLING METHOD <br /> i <br /> TANK ID 1 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSL <br /> T <br /> A 39- - � L.��-- 550 none <br /> N 39------------------ <br /> ---------- <br /> K 39 <br /> ------------------------'-- <br /> h 39- <br /> N <br /> M39------------------------•- <br /> Q LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> F1 L u_ APPROVED ___APPROVED WITH CONDITIONS __ _ DISAPPROVED <br /> ". - (SEE ATTACHMENT WITH CONDITIONS) <br /> P1 A PLAN REVIEWERS NAME fgl/rl%�---- vL ---- - - - -- -- BAT E7��j----------------- --- <br /> 0; N <br /> tt <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> SI 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 SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> CQ 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 /I/N/SPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED_ ClAled14--�1�- - .............DATE- - <br /> �� } 1.�3J_,(Sfl--------- <br /> OfFICE USE ONLY EN 13 !16 11/ 8 <br /> fifffli{ffffffffffiffffffffffffffffff{fffffffffffifffifffff{ffffffiffffffffffffffffffffffffffffffffftfffffffftfffffffffff <br /> SWEEPS 1 I COMP 1 LOC CODE DIST CODE AMOUNT DUE I AMOUNT RCVD I CKI/CASH I RCVD BY I DATE RCVD I PERMIT t <br />