Laserfiche WebLink
U ff R ft ti,ki tial*L�LIH <br /> k: APPLIC11meg FOR PERMIT ka SIN JOAQUIN LOCAL <br /> t: UNDERGROUND TANK 1601 9 HAllLTON AVB., STOCK70Y <br /> V. CLOSURE OR IBINDOMMEN? Telephone (2091 168-N10 <br /> t:fftl:ki:ff t1:911:ti:ff Vt kiln t:ti:R:t1l:R.:R III:t t:t t:LR:R LIR III:ti:ff R4 ft:ti:ff R:tt:R: OCT Q5 1989 <br /> APPLICATION FOR PERMANKIT/TRMPORIRY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND 1112IRD&HVI 4AILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL BATH. iO NOT WRITE IN III SHADED AREAS. INDI <br /> REMOVAL ..... TEMPORARY CLOSURE — ABANDONMENT IN PLACE <br /> EPA SITE I (- A 09 S 141y PROJECT CONTICT & TELEPHONE 1 '011L-ICA 04 F 15 A� <br /> -i-V--II I--- Z- <br /> F FACILITY NAME ONE I <br /> I ---- 5 A3E A o i r,V L I es <br /> C IDDRESS-_ 3 DSI <br /> (�� — <br /> I — r pe r R fbI, <br /> L CROSS STREET <br /> I . <br /> I OWNER/OPERATOR PHONE I <br /> ----------------------------- <br /> C CONTRICTOR NAME PHONE I <br /> 0 -- UJ t LL <br /> I CONTRICTOR ADDRESS P6nn C7 3-3 bS CA LIC I <br /> CLASS <br /> I INSURER I 1rJ5 VORK.COMP.1 <br /> A ------------- <br /> C FIRE DISTRICT PERMIT I/IVSPTR <br /> 0 LIBORI?ORY WINE PHONE I <br /> R Al U rO M 4-Z <br /> SAMPLING FIRM' /�. /J V I r* xAe,--0r41- SAMPLING HETIOD <br /> ? ?IRK ID I TANK SIR[ CHEMICALS STORED CURRENTLY CHEMICAL; STORED PRIVIOUSU <br /> 1 39- .2- '0(/ 7— & 600 A'( 1-c j c ej� 10^Al- & <br /> 1 39--7--------- <br /> LIST DDITIONIL ?ARK INFORMATION AS NEEDED Of SEPARATE FORM <br /> P X APPROVED IPPROVRD WITH CONDITIONS DISAPPROVED <br /> L y 9 ATTACHMENT vi CON <br /> A PLAN RIVIEVERS NAME /1� x DATE <br /> ff=111-le,ATTACHMENT <br /> �-11 I <br /> APPLICANT MUST PERFORM ILL WORK If ACCORDANCE WITH SIN JOIQUIN COUNTY ORDINANCES, STATE LIVS, AND RULES AND REGULATIONS <br /> OF THE SIN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> 11 THE PERFORMANCE Of THE WORK FOR WHICH ?HIS PERMIT 12 ISSUED, I 911ALL NOT EMPLOY IVY PERSON IN SUCH MANNER 13 To BECON <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY ?HIT IN THE PERFORMANCE OF THE 1021 FOR VNICH ?HIS PERMIT 13 ISSUED, I SHALL EMPLOY PERSONS SUBJBC <br /> TO WORKER'S COMPENSATION LIVS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED <br /> OFFICE USE ONLY--BH 23 046 12181 ---- --- <br /> SWEEPS I—I—COMP I ILOC CODE IST CODE AMOUNT OUR AMOUNT RCVD RcvD By <br /> CKI/CASH DATE RCVD PERMIT I <br />