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nvairem AerLzrererKrNlffIll rtrtrtrertrRrererKrerNr,,�et Nr <br /> APP6ICATIY,FOR PERMIT a SIN JOAQUIN LOCAL HEALTH DISt@[C.ty: <br /> UIDERGROUND TAN[ t: 1601 B HAZE6TOY AVB., STOCKTOI CAt: <br /> t' <br /> G CLOSURE OR 111NDONMEYt t: Telephone (2091 160-1120 t: - � \spil <br /> Gtrtr trtr tr tr trtr Nrttr Rrtrkrtrtfi�trtr trtrtrtr Nrtr tr Fti Nr trtrtr trtr tr t �k �F��� <br /> APPLICATION FOR PIRMANEIT/TBMPORIBT CLOSUIE OR ABAIDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSftBS S*Go P �S <br /> ?HIS PERMIT BKPI@ES 90 DAYS FROM THE APPROVAL DITR. DO NOT 1117E IN IAT SHADED AREAS. INDICATE PB It TYPE—C3 <br /> REMOVAL __ TEMPORARY CLOSURE _ ABANDONMENT IN PLICI <br /> EPI SITE 1 CA497I520834 PROJRCT CONTICT A TELEPHONE 1 <br /> P FICILITY IAMB DEFENSE DEPOT TRACY PHONE 1 (209) 832-9550 <br /> 1 <br /> C ADDRESS 25600 South Chrisman Rd, Tracy, Calif. 95376 <br /> 1 <br /> L CROSS $11117 Eleventh St . <br /> 1 <br /> T OWNER/OPIRITDR PHONE 1 <br /> Y Defense Logistics Agency ( 209 ) 832-9550 <br /> C CONTRICTOR NAME PROMS I <br /> 0 <br /> I CONTRICTOR REDRESS C1 LIC ! CLISS <br /> T <br /> I INSURBRYOBR.COMP.I <br /> 1 — <br /> C FIRE DISTRICT PRRMIT 1/INSPTR <br /> T <br /> 0 LIBOR110RY IAMB PROVE I <br /> H <br /> SAMPLING FIRM' SAMPLING METHOD <br /> NDGtl�YO)�WW;tlWNItlIWIIIWIDIGpWtlW'lBl <br /> 'ARK ID D ?ARK SITE CHEMICALS STORED CURRENTLI CHEMICALS STORED PRBVIOUSL <br /> t <br /> 39- <br /> 1 39- <br /> 1 39- <br /> 79- <br /> --I LIST ADDITIONAL ?INK INFORMATION AS NEEDED 01 SEPARATE FORM <br /> ' 'QYIV�iIWW'!�'tlNpYiItlIIWiNIWWtlYYWDYYINNWW411NNWIIWYIWI NtlWi4tlIIlUWtlIipYIWWNIWBIIWIW67DWIIL'D�IICSIIWWBIIIHiYWY.W'J'19L'YIiIWLM' ItlYIIJ"�J'ItliNItlW!'IN:NINIBIIIDYW1tWW:IWNL'WAIL'IIYiIIIIIIIWWJ'J:I;WIWWIC:IhWItiNIJ11tIWLIWItlIYW ' ' <br /> i <br /> P —__ APPROVED _APPROVED VITO CONDITIONSDISAPPROVED <br /> L (SEE ATTACHMENT VITO CONDITIOYS_I <br /> I PLIM REVIEWERS NAME <br /> N <br /> Nml�' WNNV; WDNNNWY @ ' WWIWIDWABRYUNNtl�7VWN9VRl <br /> IPPLICIE? HUS? PERFORM ILL FORK IN ACCORDINCE WITH SIN JOIOUIN COUNTY ORDINANCES, STATE LIVS, AND RULES IND REGULITIONS <br /> OF THE SIN JOAOUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED KENT'S SIGNITURR CERTIFIES THR FOLLOWING: 'i CERTIFY THAT <br /> 11 THB PERFORMINCE Of THE VORK FOR WHICH THIS PERMIT IS ISSUED, I SKILL NOT EMPLOY ANY PERSON II SUCH MINNER 13 TO BECON <br /> SUBJECT TO YORKER'S COMPENSATION LAWS OF CILIFORWII.' CONTRICTOR'S HIRING OR SUBCONTRACTING SIGN/TURB CERTIFIES THE <br /> FOLLOVINC: 11 CERTIFY THAT 11 THE PERFORMINCB OF TIRE VORZ FOR WHICH THIS PERMIT 11 ISSUED, 1 SHALL EMPLOY PERSONS SUBJEC <br /> TO YORKER'S COMPENSATION LIVS Of CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 40 HOURS IN ADVANCE <br /> SIGNED DITB _ <br /> OFFICE USE ONLY--BH 23 016 12/11 — <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SVBEPS I CORP 1 LOC CODE ( DIST CODI AMOUR? DUEI AMOUNT RCVD CKI/CASA RCVD BY 1 011E RCVD PERMIT 1 <br />