Laserfiche WebLink
F1 2'e7 <br /> i ttL'ttttt R:R: kRM:I'ttttt�ttL'ttttttttt.t:r lltvtYIt:tt�tM111 <br /> r APPLICI Y FOR PERMIT t: SAN JOAQUIN LOCAL HEALTH=STRICtp <br /> t: UNDERGROUND TANK t: 1601 R HAIBLTON 178., STOCKTOY CA t: f� _ <br /> t: CLOSURE OR IBINDOWNRYT t: Telephone (109) 168-3110 t: ., ) V ��IV <br /> tit:IVtIt:It:IVI%:ti'tt:tt1:11:It:Iv.ftti:RmI'Vtt.,k-1:MI:t-1:ff Aldi :Ofti:ttrtttvti: <br /> r _ <br /> APPLICATION FOR PBRMANSNT/19HPORIRY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HABIRDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT HKPIRBS 90 DAYS FROM THE APPROVAL BITS. DO NOT 11179 IW ANY SHADID AREAS. INDICATE PERMIT TYPE ISLOY: <br /> REMOVAL --_ TEMPORARY CLOSURE — ABANDONMENT IN PLACE <br /> EPA SIT8.1 — PROJECT CONTICT A TELEPHONE I ��- —^— <br /> F FACILITY NAME _ 3 PHONE 12Lq_gt}9 -cjgzO <br /> 1 -- — <br /> C ADDRESS -74� E . ct T �w1�y SicK�Te1� <br /> 1 <br /> L CROSS STRBIT � �- <br /> I zr <br /> T OWNER/OPERATOR . PHONO <br /> Y �eLEfL G Ism l2�11 31- 7-I 1 <br /> C CONTRICTOR NINE PIOUS <br /> 0 21Qo C'ti1 E ` - v, i3 <br /> Y CONTRACTOR ADDRESS CI LIC 1 I- SS , <br /> I INSURER SN A YORK.COMP.t C'Z5 11�tQ Y <br /> C FIRE DISTRICT -SV7\l,O c PERMIT 1/113PTR <br /> T _ — <br /> 0 LIBORITORY NINE SFqU0 �,WPL-Y04- PHONE I'7c-I -7-0-- h�i1 S <br /> R — <br /> SAMPLING FIRM' (Lpp�FI1Pi Stk lNF-k21N — SAMPLING METHOD Z>Y& <br /> WpkOYWWWIWDWWtldN NWNYWDiWYIIN ---- <br /> TANK ID I TAKK SIVE CHEMICILS STORED CURRENTLY CHEMICALS STORED PRIVIOUSL <br /> 1 <br /> 1 39 /O(o0_C�o2 —_--- <br /> Y <br /> 39- 77(& c -U_3 <br /> -0y eled <br /> 39-1G (o '©/ In <br /> 39- <br /> - —� LIST ADDITIONAL TINK INFORMATION AS KREDED ON SEPARATE FORK <br /> WdWdDWddYNYWIdWdWWDIWWWWYWIWWWtlWWIWWWKWdW. dKIWIIWdtlligdWWIIgIUWIWdIU'IJWddI''ddIWdKWdNlKdlld�'tlW!dWdNddNDIIW9ddNdWidddtlDldldYdlldWlDddWIWdNYNddWdWWIWIdWWWDIdYWWDI�IdWWWdIdWWWDWYd <br /> P APPROVED _✓APPROVED PITH CONDITIONS DISAPPROVED <br /> L (SEB ATTACHMENT WITH CONDITIOWSI— <br /> A PLAN RRVIEYERS WIME -c' '�! DIt6 %G -5- <br /> WWWYWYtlYWYdWIYIN <br /> APPLICANT MUST PERFORM ALL YORK 11 ACCORDANCE WITH SAN JOIOUIN COUNTY ORDINANCES, STATE LIPS, AND RULES IND REGULATIONS <br /> OF THE SAN JOAOUIN LOCAL HEALTH DISTRICT. DINER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR IHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY IVY PERSON IN SUCH MANNER IS TO BECON <br /> SUBJECT TO YORKER'S COMPENSITION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CBRTIFISS THE <br /> FOLLOWING: 'I CERTIFY THAT 11 THE PERFORMANCE OF TIIR 1091 FOR WHICH THIS PERMIT 13 ISSUED, I SHILL EMPLOY PERSONS SUOJEC <br /> TO YORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CA L FOR INSPE t�S AT LEAST 40 FIOURS IN ADVANCE <br /> SIGNED _ -----DATE <br /> OFFICE USE 0 Y••8 1 016 11/11SWEEPS -- — — <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> LOCOCOiE I DISI CODE AMOUNT DUE I IL AMOUNT <br /> �=I- CKI�J 59 I- IDATE RCVD PERMIT t <br /> 3 - <br /> -- -�,__- a3 <br />