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t tnl:It: k}:klwig ti: tv L'Y tl}: t}: t't:t'v ft t} yR:tl:tytl�tl:[}!t•}: t}: ti, ft. tnl:I,,' ti, [}:t}. <br />c APPLICd FOR PERMIT [: SIR JOAQUIN LOCAL HEALTH M,CT k: <br />t: UNDERGROUND TANK t: 1601 E HIZELTOM AVB., STOC el CAg <br />t: CLOSURE OR 1BINDONNRNT t Telephone (2091 468-3420 t: <br />k� t}: kl� k}: L'}: tl� [}� t}� [l: t}� tl}� ['}� ['}� t}: ['l: t}: [1'tl Kk: Ut BB tl'tt L•}: tl� [}: [l: kt� l'}: tl� t;: k}: [}� <br />APPLICATION FOR PBRMANRIT/TEMPORIRT CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTINCES STORAGE FACILITY <br />THIS PERMIT BKPIRIS 90 DAYS FROM THE APPROVAL D118. DO NOT YIITB IN III SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL --_ TEMPORARY CLOSURE — ABANDONMENT IN FLICK <br />EPA SITE I <br />elk DD i -ZD Li — PROJECT CONT/C1 A TELEPHONEr <br />F <br />FACILITY MIME e4l PHONE I <br />C <br />IDDRESS// / 9' -01? <7 G1fii <br />L <br />CROSS STREET <br />1 <br />OWNER/OPERITO@ <br />PHONE I <br />C <br />0 <br />COMTRICTOfl MANE <br />PHONE 1 <br />--- <br />Y <br />COtlTR1CTOR ADDRESS <br />CA LIC I y/��f/� <br />CLISS(!&/ Q ' <br />R <br />YoaK.CONP.I N/ �U 74e - <br />1NsuRee �— t if <br />C <br />_.._. ---- <br />PIRG DISTRICT PERMIT I/IISPTR <br />0 <br />R <br />LABORATORY NAME <br />[ %7� lr G7.�t�/ L �. <br />HONE I? <br />J��✓ <br />( -- .._—_..— —. <br />SAMPLING FIRMt /�J 'j' (�i6 I SAMPLING METHOD ,'-•,/ r 0-7- 407-0 flatt,'O/-e- <br />- <br />tlIIWWDIVILIIWVWIWWpWVWIIIIIVIHOWVIWVWVIIIIIZOO IWVWWI-------------•-------- -------- - <br />TANK ID I TANK SIZE CHEMICILS STORED CURREN?Ll CHEMICALS STORED PREVIOUSL <br />T <br />N <br />79'� Lia - - _-.-L G-.__...__...._ -- C7✓SiLL�r�, p <br />Y <br />79 -- - --- ---- ----- -- <br />179- •-- <br />-- <br />LEST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARITS FORM <br />WIIRWBIVOWWI�IIIIWVWIWWVIWIWI�VVVNWWVWWBVVWWIWO IIWIIDWVVIVWIINHY9VWWIIIWWWIIIIIIINIVIIIINDIIIIIIIWWIIIIINWVVIiVIVNIIBIIIIIVVIIIIWNIIIIIVVVVIIWIWVIIWIIIIVtVIIIWIIINVWIIDIDGiWIVVWVIIIIVIIIBBIWJIWIIJIDWIIIIWIW!VWIIIhIIIiVWIIItlWlllll <br />P <br />APPROVED _ IPPROVRD WITH CONDITIONS __- DISAPPROVED <br />L( <br />A <br />SER (SER ITTACA ENT WITH CONDITIONS) <br />PLAN REVIEWERS RAMS !N� �7-9'?--_____, <br />N <br />-- _------BITE1�_ <br />---- ------------ <br />�I <br />V9VWVWIORBWWYIWIWIRWVYWWWWWWBtldVWBWIWWWVVWVWVVWIIWWIIIIWWtl011WIVWWWOWVWWD'VIIIWIWIIBIWUI IWUtlIWVWWWIDIIWVIIHIIVIIWBWIIWWJIIDBWIIIWWIWIUWWYIWDItlIVIWNWWWWIWWIWWVVIWYNWJIWIWBiVONWVW'dIWYNAIWW41ViW�1 <br />IPPLICINT <br />MUST PERFORM ILL YORK IM ACCORDANCE PITH SIH JOIQUIH COUNTY ORDININCES, ST1TE LIPS, AND RULES IND REGULITIONS <br />OF <br />TNR SAN JOAOUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNITURS CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br />IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY IVY PERSON IN SUCH MINNER IS TO BECOM <br />SUBJECT TO YORKER'S COMPENSITION LAYS OF CILIFORIIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: 11 CERTIFY ?HIT IN THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SIIALL EMPLOY PERSONS SUBJEC <br />TO <br />YORKER'S COMPENSITION LAYS OF CILIFORNII. <br />CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br />SIGNED l " <br />-- <br />OFFICRtS8 ONLY --NII 21 046 12!11 <br />SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSfSSSSSSSSSSSS <br />SWEEPS I I -COMP I ILOC CODE DIST CODBI IMOUNT DUB) AMOUNT RCVD I CKI/CASH RCYD BY �- BITE RC VD PERMIT I <br />