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t'ti Ci'ti't� °ti'ti:ti tit.ti:ti tt'hi ti'ti ti ti'ti ty.ti'ti ki'ki'ty ti t- itititi' <br /> e APPLIL*�oY FOR PERMIT ► SAX JOAQUIN LOCAL HEILTi�. STRICT t: <br /> t: UNDERGROUND TANK t: 1601 E HAYELTON AVB., S?OCKTON CA t: <br /> t CLOSURE OR ISINDONMEYT t: Telephone 12091 168-3120 t: <br /> G titt'ti:ki tY it:tt'kt'ti tit'ty ti R:ti:ti'ti:ti:ti:ti ti it'ti:tt'ti'ti:ki t'i'ti'ti'ti'ti'ki' <br /> APPLICATION FOR PRRNANBNT/TEMPORIRT CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HIKIROOUS SUBSTIXCES STORIGE PICILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT 11178 IN IlT SHADED AREAS. INDICITE PERMIT TYPE IBLOY: <br /> REMOVAL --_ TEMPORARY CLOSURE — ABANDONMENT IN PLACE <br /> Vd{ ,.tc u�.•c - <br /> EPI SITE I t PROJECT CONTACT d TELEPHONE F (1 <br /> o"'V-C 'o e c amp /y�y (Ydn� z —94F31ti <br /> P PIC[LIT! NAME ��Q f� e rvlc PNOXB I �Q� `!31_368 <br /> A vw ! <br /> C ADDRESS ! <br /> 1 <br /> L CROSS STREET <br /> 1 <br /> T OYNER/OPERITOR PHONE <br /> !_ 'o �Qq1731 -3168 --- <br /> C CONfIlCTOR VAMEv PRONE 1 <br /> 0 <br /> Y CONTRICIOR ADDRESS q/016 ;,l L[C <br /> T — <br /> R INSURER ,Vo / f✓�me ; S YORK.COMP.I Ivo esn�(oyer <br /> — <br /> C PIRN I"STRICT <br /> :1-7-1 <br /> .ect« +.� PERMIT 1/[KSP1R <br /> 0 LdBORIfOR! MINEPHONE 1 a vr�7- 405-0 <br /> R / - <br /> SIMPLIYO FIRMt 0611 • C11CL-rLW'4-1 fora ry <br /> SAMPLING METHOD —� <br /> m111C011mp1mIV10VIImDI0WmR8dDm00DD11 Cly <br /> ?INK ID 1 ?INK SIZE CHENICILS STORED CURRENTO CHEMICILS STORED PRBVIOUSL <br /> T _ <br /> 1 ]9- 51 S -O 1 Ga <br /> zeef)O Qa! I — <br /> 1 39- <br /> ]I- <br /> 39-- <br /> - <br /> 9-]9-]9- <br /> LAST ADDITIONAL TIME INFORMATION IS NEEDED OY SEPARATE PORN <br /> D ' uuumlaDmmimmmawRmllumuumuglmmmDumlNNmlumumulmMlmmuoRluulmmlwim11m1mD11mum1Rmm <br /> illp"R APPROVED _IPPROVED WITH CONDITIONS _ DISAPPROVED <br /> (SEH AT?AREVIEWERS NAME DATE <br /> RdmD®011mI0mmR8tlDmImOm01�INIIRmORmDI01m01�INHNDmmm®tlN8W01�IDlllmliloDY01D <br /> IPPLICIYT MUST PERPORM ILL YORK IH ACCORDANCE WITH SIM JOl0UIN COUNTY ORDINANCES, STATE LAWS, IND RULES IND REGULATIONS <br /> OF THE SIN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY ?HIT <br /> IN ?NR PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SKILL NOT EMPLOY IVY PERSON IN SUCH M►YMER IS TO BECOM <br /> SUBJECT TO YORKER'S COMPEISITION LIPS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNITURE CERTIFIES THE <br /> FOLLOWING: 9 CERTIFY THAT 11 THE PERFORMANCE OF THE 1011 FOR WHICH THIS PERMIT IS ISSUED, [ SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKNR'S COMPENSATION LIPS OF CILIPORY[l. <br /> CALL F R INSPECT ONS A LEAST 48 HOURS IN ADVANCE p <br /> SIGNED iY DATE I / <br /> OFFICE USE ONLT-•BH 2thif lI/11 <br /> SSSSSSSSSSSSSSSSfSSSSS4SSSSSSSSSSSSSSSSSSSSt4tSS4SSSStSSSSStffSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SYBEPS I COMP I ILOC CODE DIST COD IMOUVT DUH AHOUXI RCVD CXI/CASH — RCYO BY I D118 RCVD— — PERMIT I - <br />