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APPLICATION FOR PERMIT SIN JOAQUIN LOCAL HEALTH DIStRICTI: <br /> t: UNDERGROUND TANG F 1601 B HIXELT01 AFB., STOCKTON Clt: <br /> t: CLOSURE 01 AI/MDONMEIT t Telephone (209) 168-3120 t: <br /> k til;akYtikC tt:t;1111C;;tiftl;C;I;L;t;TGC;C;t;t;C;LY ti t;C;C;kS ti t;ti <br /> APPLICATION FOR PERMANENT/TBMPORIRY CLOSURE OR IBANDOMMEIT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> ?HIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DAIS. DO NOT 11118 IN 111 SIRDII AREAS. INDICATE PERMIT TYPE ISLON: <br /> "E-�xe.+vTt <br /> =REMOVAL —_ TEMPORARY CLOSURE — ABANDONMENT IN PLACEK—YL SrVATI.AsD,uR <br /> EPA SITE I CAD &"' 9WF7b PROJECT CONTICT A TELEPHONE I leL)(r MFi..WM 466_ // <br /> P FACILITY tlAMB'8eEA AGIZICUL'IUhAC- X10 ?NodE I 4&10 .moi 9111 <br /> C ADDRESS 1755 N. 3ti'c�1I JRY� STK /y 04 <br /> 1 <br /> L CROSS STRIET �nI�TE�Im WD <br /> 1 OWNER/OPBflITOR L�ZtARICUL7Ul�!}LiJ1cE PHONE I <br /> ' 1P. D. BOX Zo1c6R STCXKSOIU LA_ 41 -54II <br /> C CONIIACTO7IDDRISS <br /> PdON6 1^ _-- -- <br /> 0 <br /> Y CONTRACTOCI LIC 1 CLASS <br /> T _ <br /> I INSURER SEIX � D YORE.COMP.I <br /> C FIRE DISTRICT CEN STCC PERMIT I/INSPTR <br /> T <br /> 0 LABORI}ORY N1M8K(EINFEY � PHONE I <br /> R 209-4g4, -DISG <br /> SAMPLING FIRM* Kf E/1vF�cT �' t � SAMPLING METNOD SIL_ <br /> TANK 10 1 TANI SIZE CHEMICALS STORED CURRFATLI CHEMICALS STORED PRRVIOUS6 <br /> T <br /> A )9 _-�- -- W�D�ca) COGS AIIR CQScCa,IJE <br /> N )9- _ — <br /> 1 <br /> - — LIST ADDITIONAL TANK INFORMATION AS IEEDBO ON SEPARATE FORK <br /> NRNINNNYYYNNNWWYdVW� �MNHYR!IWRNIIWi!WW"WIRRWWtlYRYIL'LWR'RItlRWiINtl14YYYJiiIYIiWV�JIRIYOtRNWV�IWWWWWYWWiIWWWWYYWY4RIYIWWtWN4411'WWIWWYYW <br /> _ APPROPED <br /> L _APPROVED WITH CONDITIONS _ DISAPPROVED <br /> L <br /> A PLAN R8F[BYBRS YlMB (S88 ATTACHMENT WITH CONDITIONS) <br /> _ DATE <br /> APPLICANT MUPA <br /> ST PERFORM ALL RORK IN ACCOIDANCE WITH SIN 11fflj%WajjjjCES, STATE LIPS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICATURS CERTIFIES THE FOLL � {;� if T, <br /> IN THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT y`Vg� NOT EMPLOY ANY PERSON IN �� <br /> SUBJECT TO YORKER'S COMPENSATION GAYS OF CILIFORNIP g �T SUBCONTRACTING SIGNATURH CBRTIP� N <br /> FOLLOWING: 11 CERTIFY THAT IN THE PERPORMANCB OfffN�9DNlCNYTA(HL pt��IS ISSUED, 1 SHALL EMPEdI SERFON§ S9t�J6C <br /> TO YORKER'S COMPENSATION LAWS OF CILIFORVII. t N VIRONM <br /> ENTAL HE LTH <br /> CALL FOR INSPECTIONS AT LEAST 40 HOURS IN ADVANC�RMIT/SERVICE• <br /> SIGNED DATE <br /> OFFICE USE ONLY--BH 23 016 12/81 APERMII <br /> SWEEPS I ICOMP I I LOC CODE I DIST CODER AMOUNT OUR IAMOUNT RCVD I CKI/CASO IRCVD By I DATE RCVD I <br /> 1 I��_ 1 L J 1 1 <br />