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t:Litt:R:Lnll"t:R ft Lit ti:ti:ft Vft ff tl:ft ft R:R:ff R tl:t I!tnt:0 t r Lv fftv- <br /> APPLICATION FOR PERMIT r SAM JOAQUIN LOCAL HEALTH DISTRICTI: <br /> UNDERGROUND TANK r 1601 9 HAIELTON AVE., STOCKTON Ckt: <br /> -3420 <br /> CLOSURE OR 11IND09MENT Telephone (209) 468 t: <br /> t41 tt:ffR:fftYt1:tYV11tvR tt R41' <br /> ArR I <br /> APPLICATION FOR PERMANENTITIMPORIRY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE 11 1111 SIRDED AREAS. INDICATE pRjMIj TYPE IjLOW. - [ HEALTH <br /> pEj,[v,jj I SLi&ICES <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN ?LACS <br /> EPA SITE I S�yPROJECT CONTICT i TELEPHONE I Tom man <br /> F FACILITY MAN[ ----[PHONE 1, <br /> 4,7 / r' 110",� �,, <br /> P4�'j I' / -3 -7vrcE <br /> C ADDRESS <br /> Vof <br /> L CROSS STREET <br /> _57f <br /> OWNERIOPERATOR PHONE I <br /> 1-4'.i <br /> 14 1 If <br /> I 11111111OR 1111 7" PHONE I <br /> 0ur <br /> I CONTRACTOR ADDRESS, 5-?4 CA LIC I <br /> CLASS A, <br /> cr <br /> R INSURER 14 _Z- LVORK.COXP. <br /> C FIRE DISTRI PERMIT I/IMSPTR <br /> 7 ___ IZ4& "o `I-2 f1# ta7 2 <br /> 0 LABORATORY MINI PHONE 10?0�_ <br /> R y;01a <br /> SAMPLING FIRM' zr'(fING HErROD <br /> ?III ID I TANK Sit[ CHEMICALS STORED CURRENTLI CHEMICALS STORED PRIVIOUSL <br /> I <br /> 1 <br /> 1 31- <br /> 1 31- <br /> 31- <br /> 39- <br /> LIST I ITIONIL TANK INFORMATION AS NEEDED 01 SEPIRITE FORK <br /> ••"".. uuuuwL7WwJtiuWiWuulYwYwuWiYtiWIiNWUWWIi P Withfl <br /> APPROVED —APPROVED WITH CONDITIONS DISAPPROVED <br /> (SIR ATTIC mill WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME DAYS— 01 <br /> "I'll............i ..."I w=&=wu"w ------ <br /> APPLICANT MUST PERFORM ILL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, 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 /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED, I SHALL No? EMPLOY ANY PERSON IN SUCH MANNER IS To BEcomi <br /> SUBJECT To VORIERIS COMPENSATION LIVS 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 SUBJRCA <br /> TO WORKER'SC70 ENSANOM LIVS OF CALIFORKII. <br /> CALpeF,(OR I SP;9 AT LEAST 48 HOURS IN ADVANCE <br /> SIGNS <br /> OPPI 23 046 12111 <br /> SWEEPS I COMP I LOC CODE DIST COD AMOUNT RCVD KI/CASH RCVD BY I 'DITB RCVD I PERMIT I <br />