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xexexxx•tx+x�tx txtt'Ittti'tt'ttLitt ettx'tvkvt?'tttx.tvkv;IVtt.t?:Y <txtx'tit? <br /> t: <br /> APPLI ON FOR PERMIT r SAN JOAQUIN LOCAL HEAL'*�STRICT ��..�.� <br /> G UNR400 TANK a 1601 E HAZELTON AVE, 5T�CKTON CAS/ <br /> e N CLOSURE OR ABANDONMENT w Telephone (209) 468-3420 r' <br /> !!'.t't�l�llt?�!r!?�t?�t?:??ti�!?�!?!?�ITNR:trlx!?:!?:?�:i{t�!?:!?:!r!?'C?•t:.^ `�� <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HA2ARD0 SUBS( S"STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 PAY$ FROM THE APPROVAL DATF, On NOT WRITF IN ANY RHADFn ASEAS. 1WDICAT9 VOMIT TYPE DELCIJ: <br /> REMOVAL TEMPORARY CLOSURE _ ABANDONMENT IN PLACE <br /> EPA SITE 8I D PROJECT CONTACT 1 TELEPHONE 8�h� <br /> F FACILITY NAME 4 PHONE 8 y <br /> A <br /> C ADDRESS _ <br /> I <br /> L CROSS STREET (� <br /> 1 <br /> T 9WNER/DPERATOR PHONE a <br /> Y '�L /Y✓� CIA 0-1-� s CN�n z c uJ CL F 2�c� <br /> C CONTRACTOR NAME PHONE 8 <br /> N CONTRACTOR ADDRESS 7 X00 OJ-4,644 Cb,- CA LIC 8 CLASS <br /> TPA _ , S0 c <br /> R INSURER � � WORK,COP <br /> r- <br /> C FIRE DISTRICT PERMIT 8/INSPTR ,•�l..ri.YL L 1. <br /> T <br /> 0 LABORATORY NAM PHONE 8 , <br /> R <br /> 76 7 <br /> SAMPLING FIRMt SAMPLING METHOD <br /> TANK 10 6 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSL <br /> I <br /> A 39N 39- <br /> • 1B <br /> K 39UL'C'i <br /> ,� i <br /> LICT ADDITIONAL TANR INFORMATION AS NEEDED ON SEPAKAit rUKM <br /> P APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L _ ISE ATTACHMENT WI CONDITIONS) •. <br /> PLAN REVIEWERS NAME G �t'�.. --DATE .. 7— <br /> A <br /> N ^- ............ .. . <br /> APPLICANT MUST PFRFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN 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, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWINGS 11 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA, <br /> CALL FOR INSPECTIONSAT LEAST S IN ADVANCE <br /> 6I6NED.................... .t[ �2 .. . <br /> DATE - -f '"" <br /> OFFICE USE ONLY-^FN 2J 046 12/88 <br /> ssssssssssssssssssssssssssssssssssssss s$$$$sss sssss ssssss s ssssssssssssssssss sss ssssssssssssssssss ssssssssssssssssssss ssss <br /> SNE£PS 8 COMP 8 LOC CODE OTST CODE AMOUNT DUE AMOUNT RCVD CKe/CASH I RCVD BY I DATE`RCVO I PERMIT <br /> c= 8 <br />