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I UNDERGROP' - 'TANK t 1601 E HAIELTON AVE., STOCKTON CA p: <br /> I CLOSURE 00. 01PONMENT f;. Telephone (209) 468-342Cy <br /> P N <br /> {°APPLICATION FOR PERMAMENTC.TEMPORARY CLOSURE OR ABANDONMENT IN PLACE Of UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY ., <br /> ' , 15•PERMIT EXPIRES 90 DAYS' FROM TI APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: i <br /> �f+' REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACEAll <br /> -- -------------- !c 77,- <br /> I. ,EPA SITE f PROJECT CONTACT f TELEPHONE I - ?w <br /> " <br /> A <br /> TF ,. <br /> ' FACILITY NAME PHONE t 6. 7 <br /> R <br /> 4 }T �C' jADDREsS /C-• /. J c /Y/c r /i pct 1-7 <br /> I <br /> CROSS STREET <br /> �.Td <{OWNERlOPERATOR PHONE I _ _A <br /> - z <br /> k�a .> 6 7 <br /> 100 <br /> pi {C ;'CONTRACTOR NAME - I PHONE I .� ,-. r•� C / / ! � +. <br /> fCONTRACTOR'ADDRESS�� � / /''-` ' ' - CA LIC Fi CLASS <br /> 1R <br /> INSURER '. / WORK.COMP.I <br /> fk } i <br /> FIRE DISTRICT PERMIT i/INSPTR <br /> r, ;a LABORATORYNAME C'rHONE f'PJar/ <br /> n R, y .•: f ?' <br /> �r �r 1 SAMPL1Nfi TIPSAMPLING METHODxv <br /> TANK ID I TANK SIZE CHEMICALS STORED CURRENTO CHEMICALS STORED PREVIOUSL r W <br /> ----------- <br /> ---------------- <br /> 39- <br /> - <br /> 9 --------------- #t <br /> a ----------------- <br /> r e�7; — <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM ' <br /> APPROVED APPROVED WITH CONDITIONDISAPPROVED <br /> Y n µ ---- <br /> TTACHMEHT WITH C TIOHS) M 'u <br /> kWtkEYIE0S NAME - --------------- GATE �� 7 <br /> -- - ----------- <br /> �APPIICA�IT MUST`PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> h'<TWSAN.JOAOUIN LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT Y <br /> 411N;T1 PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> E�C'11,a0�YfR'S COMPENSATION'IAVS Of.CALI,FORNIA,' CONTRACTOR'S HIRING OR SUbCONiRACTING SIGNATURE CERTIFIES THE <br /> ij 0Y11NC+t�i I'1ERTIFY_ 11AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJEC . <br /> ,;TU;•YORKFR'S.tOMPENSATIBN LAWS Of CALIFORNIA.' <br /> CALL=FUR TNS TIONS AT 4AS 48 .HOURS IN ADVANCE F <br /> SIBIIED N Lam- =f ................... <br /> --- - - ----- - GATE----Z:--- ------ <br /> ICE -- r <br /> f3E:.01lY- Eta "?Tr' <br /> 1e Y <br /> ffffff�ffSfffffffffffftffffffffftffff.Stitftfttfffffftifffftfffffftfffffffffffffffffiffffffffffftfftttttftffffffffffffffff # <br /> _pE `COMP /0 LOGE ;015 CODEI AMOUNJA_ AMQUNi RCVO-I CK1/C45H 4D BY ,BADE CVD PERMIT t ti <br />