Laserfiche WebLink
ha kfi kfi Cfi kfi R.ft:ti:Cfi tfi Gti kfi kt!fi tt:R:t7:R:R:R:Rett:ti:kfi,ki:tic 9 kfi.ti:Pf tv RM <br /> APPLICATII ° TANK R PERMIT k: SAN JOAQUIN LOCAL HEALTH DIST T k D � t��^ r <br /> *{ k; UNOERGF 1601E HAZELTON AVE., STOCKIA G: <br /> k: CLOSURE OR ABANDONMENT k: Telephone (209) 468-3420 g �1 <br /> • !:! <br /> .'6/.-A <br /> ! <br /> �FL7� 7i� �c Go X22 1989 <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT [N PLACE OF UNDERGROUND A DOUS SUBSTAN E ORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATEEWHI R,{E04WNEALTH <br /> PERMIT /SERVICES <br /> 1 REMOVAL TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br /> ' EPA SITE A— PROJECT CONTACT f TELEPHONE A - <br /> CAC o0o rso��3 CNA,6 o <br /> F FACILITY NAME CAI_7—O A)S. IM/� �14PI7 PHONE A ;5209 OIYF- P7 410 <br /> A - <br /> C ADDRESS 3�a �. �/M(0LV �e467- 1C/,TOIJ e,4 <br /> I _ - <br /> L CROSS STREET y FA y ETT& 5r2�6-7 <br /> 1 <br /> T OWNER/OPERATOR STRTL` PHONE A <br /> C CONTRACTOR NAME SE � e D — PHONE # a 0 _ Say 0 65 3 <br /> N CONTRACTOR ADDRESS �/3 W. /�7ArGH (rGb�• CA LIC f yy9�(y cLassA B 6 <br /> T - <br /> R INSURER WORK.COMP.A <br /> _—_—_— <br /> C FIRE DISTRICT �� or �TDCKToAf PERMIT A/INSPTR <br /> 0 LABORATORY NAME (? aW G J,4T� 1-46 - PHONE A sal—`1050 <br /> R -..----_ FIRM*0141 r�Jg7�ee LAkB� 6 46 Y� <br /> SAMPLING FIP,M! �. SAMPLiNf, METHOD 6 kvia—s <br /> -- mtmNaakmimunm�uN mm iiar�r�auiimmmNmmm — ?v��S <br /> TANK ID A TANK SIZE CHEMICALS STORED CURRENTLYCHEMICALS STORED PREVIOUSL <br /> T _ a o 00 G�k 1- G14s <br /> N39 ------------------- - <br /> K 39 - -- - - <br /> 39 LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> � �II�MMIImfIIX�IXImmmNflllHlilfl��IflNIImIOIIIMIflmmNfl flmXII�IhA10111flINIflGIWdmXNMRtGllllp�llll!lflmmlpflPAfi�XNII%hl�glOmtmm�IIIInMIIXII�(dII�RMiMUmIMAIMIIOBIIpImN@V�mmflIIIIPIINIP�IP18111V1811@II�MflIpPG�I!Iml <br /> P APPROVED APPROVED WITH CONDITIONS ____ DISAPPROVED <br /> L (SE ATT HMENT WITH CO DITIONS) F Ali <br /> A PLAN REVIEWERS NAME _________________ /____ DATE_ ----------- <br /> !�__: __________ <br /> ------------------ - - -- <br /> N <br /> . 81N�IIImIMIIIIMBI�IIIII�1ktIIII�IIIIIIm11M�llliAm@MIIIOMINIIIIiplNmmnlmP6RflMImmmDllml�m NmmIIMIm10pImI�RImXll�ll9m@IPIINIImRIAWIflI�IImI�RmlmnNlml <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN 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 BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CAL FO �I�N,�QSPEnC-TIO S ATLEAST48 HOURS IN ADVANCE k <br /> SIGNED - �Y==- '" '"`"""`--------------------------- 0 � --" I---------- <br /> GATE_ _ _ <br /> OFFICE USE ONLY--EH 23 0$6 12/08 <br /> ffffffffffffffffffffffffffffffffffffffffffffffffffffffftfffffffffffffffffftffffffffffffffffffffffffffffffffffffffffffffff <br /> SWEEPS A COMP AI oc caLDE DIST CODES AMOUNT DUEAMOUNT RCVD- CKA/CASH RC� VD BY I DATE RCVD PERMITAl <br />