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t-It It R tt N act,tv ttttt ItItItu t t It tt,a. It t <br /> It It tt�It ItIt �ti'tt�It�It It tt't t <br /> t: APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICTt: <br /> t: UNDERGROUND TANK t: 1601 E HAZELTON AVE,, STOCKTON CA t: <br /> t: CLOSURE OR ABANDONMENT f Telephone 12091 468-3420 <br /> !?!x!?!t!:!?!> <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE 1N ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> -( REMOVAL --- TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE 1{(-/qc,��t�/ ,�/ij� PROJECT CONTACT i TELEPHONE t C s <br /> F FACILITY NAME / - _ - �`J 6�6'� <br /> A f ir PHONE t ? <br /> C ADDRESS <br /> I —_._— <br /> L CROSS STREET Ll <br /> i OWNER/OPERATOR <br /> Y PHONE 1 _ <br /> C CONTRACTOR NAME <br /> O PHONE 1 <br /> N CONTRACTOR ADDRESSed <br /> T , CA LIC t CLASS <br /> R INSURER ` p <br /> A _-----1� :,r P a <br /> C <br /> FIRE DISTRICT `C' /oc � �S <br /> T 7cs� PERXIT 1/INSPTR <br /> 0 LABORATORY NAME/ <br /> R CSL &I fn PHONE 1 --- <br /> SAMPLING FIRML - 0 - <br /> SAMPLING METHODS _ <br /> TANK 10 1 U <br /> T TANK SIZE <br /> A S?i`t ' Z CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> 39- ^l. -- r <br /> K 39- <br /> c <br /> 31 <br /> ---------------------------- <br /> 39---------------------------- <br /> LIS <br /> ------------- <br /> -------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> !�_ APPROVED _APPROVED WITH CONDITIONS <br /> REVIEWERS NAME p (SEE ATTACHMENT WITH CONDITIONS---- <br /> LAN DISAPPROVED <br /> _4' <br /> ----------------------------------------- <br /> ------------- __GATE _ <br /> PPLICANi MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> F THE SAN JOADUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERfORXANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br /> LLOWI i0 YORKER'S COMPENSATION LAYS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> ILWORKER' 'I CERTIFY THAT !N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJEC <br /> 1 WORKER'S COMPENSATION LAYS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> NED <br /> Ffcf USC ONLY-41f 23 041 12/1/---------------------------------------------------------DATE <br /> if4{ftiiflilfifff�asts:titlflillsftisillfilliftffilfiillliflfilsftisstictscfflillfct sittttttsstssfststttittft !ftsf <br /> [PS 1 CDMP 1 ILOC CODE 40IS1, AMOUNT eua AMpuNt HCVD 1 �Kt/CAL'N k:VY 1; 1 Pe C ltvK 1 nAhN�• u <br />