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Gt2 tt kt t1:11ttIt:It:It:I It:It'R:it It a:a a It:ItltMtI lR 1ktat'tt�t6 ti t$tY <br /> I. APPLICAT!^' FOR PERMIT f SAN JOAQUIN LOCAL HEALTH P 'ICT t, <br /> t: UNDER No TANK t: 1601 E HAZELTON AVE., STOCnrJN CAt: <br /> t: CLOSURE OR ABANDONMENT t: Telephone (209) 468-3420 <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM HE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _✓__ REMOVAL ----- TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br /> EPA SITE i C 1 45/7 PROJECT CONTACT t TELEPHONE i Logv V <br /> F FACILITY NAME Co OF q¢EA //8roy9 LoY23/ r44P8 9 <br /> A EL /75 /SD -/9 I)7o ooD PHONE I <br /> C ADDRESS 2 S? LJ LA tNt� AL ALTH <br /> [ C olJ S�ockha� ALIS SzO� PERMIT/SERVI S <br /> L CROSS STREET <br /> 1 rh0u2 F/ELD £. <br /> T OWNER/OPERATOR <br /> Y PHONE 1 Zd 9 &II(P3-(o(0 3 Z -NElsa u Re z, <br /> 4" <br /> C CONTRACTOR NAME <br /> O PHONE I <br /> TCONTRACTOR ADDRESS 5 CA LIC 1 , / CLASS <br /> P. INSURER � `Y 3 <br /> A WORK.COMPA <br /> TFIRE 01STR1CT 5ALi a.)A )Iti, �QtT FQe)ku PERMIT t/INSPTR <br /> 0 LABORATORY NAME * PHONE t ' 7) (f� <br /> R l7 <br /> SAMPLING FIRMt It <br /> I ( SAMPLING METHOD <br /> T <br /> TANK 10 i TANK SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> I <br /> A 39-- <br /> -- <br /> N -- <br /> K 39- <br /> 39- <br /> 39 <br /> --------------- <br /> M 0 LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P �__ APPROVED _ APPR04ED WI1H CONDITIONS __ <br /> L (SEE ATTACH NT WITH CONDTONS) DISAPPROVED <br /> A ALAN REVIEWERS NAME __---__ L <br /> N --—�=-'�- --- --y[ti==1=C=--- -------- DATE----�1'�� !f� <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 SHiLL-NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <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, 1 SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CAIi� F(ER SPECT ON T LEAST 48 HOURS IN ADVANCE <br /> SIGNED //JJ��—��� _ <br /> OFFICE USE ONLY-- N-YJ 0W11/A8 ------ -------- - ------------------------------DATE_1/__ <br /> ssssssstsssssssssssstsssssssstssssstsssssssssssssssssts is stsstsststssssssssssstsssssisssssstsststtstsssssstsssssstsstssss <br /> SWEEPS 1 COMP t ILOC CODE IDIST CODC1 AMOUNT DUE I AMOUNT RCVD CKI/CASH I RCVD BY DATE RCVD PERMIT f <br />