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It:It:tv h;,:It It tit:It:It:It:It"It:R.,Vv It:tv It'IV It:k:v It:R.,Il"R.,It,J'�:.It:I <br /> APPLICIV '01 PERMIT SIX JOAQUIN LOCAL HI <br /> UNDIRG*KD nu 1601 E HAIRLTON AVE, <br /> , STOCKTOY CA <br /> t: CLOSURE OR IBINDONMENT Telephone 1203: 168 1120 <br /> vtl:ti.ati It:tv It:It It:III:vt: t:a<a Itv a:ti:It:It:a tvt.l:It:a It;It:a a:a:ty It:II: MAR 201989 <br /> APPLICITION FOR PRRHAWRIT/TEXPOURY CLOSURE OR IBAIDOMMEHT IN PLACE OF UNDERGROUND HAZARDOUS SUgSTIWCES STORAGE FICILI4Y <br /> THIS PERMIT HIPIRES 90 DAYS FROM THE APPROVAL D179. DO NOT 11119 IN III SHADED AREAS. INDICATE PERMIT TOE gxL-0-W-- <br /> /RIMOYAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPI SITE ICAC 60o //P/l 41-a9 PROJECT CONTACT i TELEPHONE lwevrE" A—irdsw0'ago :a- <br /> F FACILITY MIKE <br /> I ov"wl PHONE I 0 - 6 /.2 �4 <br /> C ADDRESS <br /> 1 Tom_ TIQ CA to <br /> ge or <br /> L CROSS STREIT <br /> T OWNER/OPERATOR PHONEI <br /> 1 040 <br /> C CONTRICTOR wlmglksl�_ PHONE I <br /> 0ev 2 <br /> 1�k, CL LIC I <br /> I CONTRACTOR ADDRESS ��03rr .1 <br /> TZ2 <br /> T 41CLASS <br /> I INSURER WORLCOMP.1 <br /> C FIRE DISTRICT <br /> PERMIT I/IMSPTR <br /> 0 LIBORITORY NINE <br /> PHONE I <br /> som_— 2 1 1wra NNirG Sola <br /> SAMPLING FIRM, m SAMPLING METHOD YN'Dart- lr&.VA� <br /> WIMMININU 12191 __L'__ <br /> TANK ID I fill SHE CHEMICALS STORED CURRENTL CHEMICALS STORED PRRVIOUSL' <br /> "I e4_661-A <br /> 35- G <br /> J9- <br /> 31-- <br /> LIST ADDITIONAL TANK IMFORMITION IS NEEDED DO SEPARITI FORK <br /> Bullww I ii <br /> L �?_II <br /> P PROVRD WITH CONDITIONS DISAPPROVED <br /> (SEB ATTACHMENT WITH CONDI?IOXS) <br /> A PLAN RIVIEVIRS NAME ATE <br /> IPPLICII? MUST PERFORM ILL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, IND RULES IND REGULIfIOMS <br /> OF TER 511 JOAOUII LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNITURE CERTIFIES THE FOLLOWING: 'I CERTIFY UIT <br /> IN TER PERFORMANCE OF THE WORK FOR WHICH ?HIS PERMIT 13 ISSUED, I SHALL HOT EMPLOY LOY PERSON IN SUCH MINVER IS To BECoMl <br /> SUBJECT TO YORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY ?HIT 11 THE PIRFoRKIMCg OF THE TORI FOR WHICH THIS PRRmIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJRC! <br /> TO WORKER'S COMPENSATION LAWS OF CILIFORXII. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED <br /> O _ <br /> I )Aeoe <br /> I ONLY 8N <br /> SWEEPS I I COOP I LOC CODE DIST CODR[ AMOUNT DUE AMOUNT RCVD ;t=zCKl/CASH RCVD BY t DATE RCVD PERMIT I <br />