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a APPLICAT'°"''OR PERMIT a SAN JOAQUIN LOCAL HEALTH D' ST N <br /> r i a UNDER6.,od TANK # 160I E HAiELTON AVE., STOCli.,o/CA <br /> # CLO RE OR ABANDONMENT # Telephone (209) 463 34?0 a v 0 <br /> a s Haa#a f'.er�aIf # DE 2 �Q <br /> APPLICATION FOR PERMAN\T/1 ARY CLOSURE OR ABANOONMENTTIIN PLACE OF UNOERGROUN RDOUS SUBSTANCES' STORAr, F%c?Li1' w <br /> THIS PERMIT EXPIRES 90ROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMf0bbMIWL HEALTH <br /> PERMIT/SERVICES <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE t PROJECT CONTACT A TELEPHONE 1 <br /> F FACILITY NAMES+�Q��� PHONE <br /> A <br /> C ADDRESS �o7O S. �i7ECisGY S'TT S�pC/CT©� 9�. 704�; <br /> I <br /> L CROSS STREET �Ty STi�E7� <br /> 1 <br /> T OWNER/OPERATOR PHONE 1 <br /> Y ��917 FC�i9/Y/`9 0??ny�fP'aZ/So2� <br /> r. CONTRACTOR NAME "jQQL[7 GO^Lr? PHONE A <br /> 0 <br /> N CONTRACTOR ADDRESS g,-,7p cS: CA LIC t ��/Q CLASS,,�� G✓�0 <br /> T <br /> R INSURER WORK.COMP,1 ,:5-7/ <br /> A <br /> C FIRE DISTRICT/%�TyoF S'Ta-eC70N PERMIT t/INSPTR <br /> T --- -- <br /> 0 LABORATORY NAME PHONE t <br /> R <br /> SAMPLING FIRM- SAMPLING METHOD Gfy��ylJE.�i <br /> TANK ID 1 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED REVIOUSLY <br /> T <br /> A39-_....& f-------- <br /> N9--_+l-al la---------Lt! <br /> Y. 39 <br /> ---------------------------- <br /> 39- <br /> ---------------------------- <br /> 39- _ <br /> ---------------------------- <br /> LIST ADDITIONAL TANK INFOkMAT10N AS NEEDED ON SEPARATE FORM <br /> T T,u 1 <br /> P APPROVE APPROVED WITH CONDITIONS DISAPPROVED <br /> L - (SEE ATTACRIENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME DATE_ <br /> =---- —----------------- <br /> `! w <br /> s <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, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <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, I SHALL EMPLOY PERSONS SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> S16NE - - -FIS / fKi - -- -- DATE_ <br /> OFF USE 0 <br /> ffffffffffffffffftffff ifff fffffffffiffSffffffftfffffffffffffffffiffffffffiffffffffffffftSfffffffffffffffiffffffffffffff <br /> SWEEPS 1 ' COMP 1 'LOC CODE 'DIST CODE AMOUNT DUE AMOUNT RCVO ' CKt/CASH RCVO BY DATE P.CVD PERMIT 1 <br /> e5 91) I �w <br />