Laserfiche WebLink
r IPPLICITION FOR PERMIT N Sly JOlQUIN LOCAL NEILTH DISTIICTt: <br /> C: UNDERGROUND TANK C: MI. E 011ILTON IVB., STOCKTQI�C1k: <br /> h: CLOSURE OR IIIMDONMENT t Telephone (209) 168-1120-- t' <br /> t 1 1:11 Ci R 1 t}: .111 tt}f tt:It:a tY t Ci:It tv a a It.a It:It:IT.It.tnrIt: <br /> APPLICATION FOR PERMANENT/TEMPORIRT CLOSURI OR ABANDONMENT IN PLACE OF UNDERGROUND HIIIIDOUS SUBSTIICES STORAGE FACILITY <br /> THIS PERMIT RIPUBS 90 DAYS FROM THE APPROVAL Dl?l. DO NOT AU TO IN 111 SIIADID IRE/S. INDICATE�( W-EXeAPERMIT TYPE (SLOW: <br /> — RIMOYAL —_ TEMPORARY CLOSURE ABANDONMENT 1N PLACE ` �nRV <br /> Y0 <br /> — A� SAIL iLbLll'i , <br /> LPA SITS I -fir D�I1836 PROJECT CONTACT I TELEPHONE I <br /> F FACILITY M►ML��EQ &RICLK�l>IL ►� PHONE I <br /> I 4�b <br /> 1 /DDRESS �t)4 ZE,L CROSS StutU�� <br /> 1 <br /> T OWNIR/OPBRITOR W-A Ac',o C.(.)mue.(L 5�1, I J� PdONE I <br /> I P.O . X ZDlo�3} Sro_e �1, CSE 45zc1 -,59 <br /> _L _ <br /> C COYTRICTOR YIMB SELF PHONE ly ^ <br /> 0 <br /> N CONTIACTOR ADDRESS CI LIC I CLISS <br /> T <br /> AINSURER �LF_ 1SU2ED WORK.COMP.I Z-L- <br /> C FIRE DISTRICT 14CVCu�� C 7�' PERMIT I/IYSPTR <br /> T �C "" '�� _ T U <br /> 0 LdBOR1tORY MIME ,poi/ WE5 1 <br /> R e, PHONE I e4Pq 476 —16,55- <br /> SdMP6lY16 FIRM �ES7-t4kJ1/ 1;kj, SIMPLING METIOD S014, <br /> TAXI ID I TANK SITE CHEMICILS STORED CURRENTL CHEMICALS STORED PRIVIOUSL <br /> T <br /> 1 79-_�aj3a_C) ( _ FiY10 (J/,JL EA DED <br /> Y 19-_ <br /> — LIST ADDITIONAL ?INK INFORMATION IS NEEDED 09 SEPARITB FORK <br /> DNtDWIVVtlIWWW' WWWRWiKWWWWWIIDWIWDWNIWWWNDCtlY iDWIiW'IWDIWWD0.'WIDII��IIIDWi!CWrWtIWDWWCWIWLWWWWDDW7WIIWWYCtWW!WIWHL%'IYBL'DWDWIl�n!WItliWIIpWiDIWWjItlIWWWYWDWIIDWtWICWWWDWIYH <br /> P IPPROVED __APPROVED WITH CONDITIONS _ DISAPPROVED <br /> L A S88 ATTACH KT WITH CONDITIONS) <br /> 1 PLAN RBPItYBRS NAME �� <br /> APPLICANT MUST PERFORM ILL WORK IN ACCORDANCE WITH SIN JOIDUIN COUWtY ORDINANCES, STATE LIVS, AND RULES IND REGULATIONS <br /> OF THE SIN JOAOUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNITURB CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIt IS ISSUED, I SHALL VO? EMPLOY ANY PERSON IN SUCH MINMER IS TO BECOM <br /> SUBJECT TO YORKER'S COMPEMSITION LIVS OF CILIFORNIA.1 CONTRACTOR'S UIRIWG OR SUBCONTRACTING SIGNdTURS CERTIFIES THE <br /> FOLLOWING: 11 CERtIFY THAT IN THE PERFORMANCE OF 111E YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJRC <br /> TO YORKER'S COMPENSATION LAWS OF CALIFORNII. <br /> CALL FOR INSP��E��CTIONS AT LEAST 40 rIOURS IN ADVANCE <br /> SIGNED Zell <br /> OFFICE USE ONLY--SH 21 0016 12/11 — <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS I I-COMP I ILOC CODE I DISTCO BI INOUNT Dui AMO/UXT RRCVD I-CKI/CASH I RCYD BY I—DATE RCVDPERMIT <br />