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t-trtrtrtrt ' rtrtr kir ti kt-u trtrtrtrall It trtrtrtrtrtrtr Irertr <br /> t: APPLICAI FOR PERMIT a SAN JOAQUIN LOCAL HEALTH ICTX <br /> t: UNDER6 OUND TANK r 1601 E HAIELTON AVE., STOCK WN CA t <br /> t: CLOSURE OR ABANDONMENT t: Telephone (209) 468-3420 t: <br /> DIY KKI :I :1>I gfl):.....q............aY.1 '...... <br /> ............................},'.......... <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 IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE -___ ABANDONMENT IN PLACE <br /> EPA SITE 1 C,-,C— 000 -4c ,l , PROJECT CONTACT L TELEPHONE 1 <br /> F FACILITY NAME PHONE O ,O�e21- e33. Ef5 D <br /> A <br /> ADDRESS <br /> I , / <br /> _ <br /> L CROSS STREET ,It2cej, <br /> I <br /> T OWNER/OPERATOR,—,— PHONE 1 <br /> C CONTRACTOR NAME �E/�)� �G/ �� PHONE 1 <br /> 0 <br /> N CONTRACTOR ADDRESS <br /> c A LIC 1 CLASS <br /> R INSURER NORK.COMP.1 <br /> C FIRE DISTRICT � PERMIT 1/INSPTR <br /> T <br /> 0 LABORATORY NAME PHONE 1 <br /> R <br /> SAMPLING FIRM* SAMPLING METHOD <br /> TANK TO 1 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSL <br /> T //,', j — <br /> N 39- <br /> K 39 <br /> 39 <br /> 39 <br /> --------------------------- <br /> LIST ADDITIONAL TANK INFORMATIOJ AS NEEDED ON SEPARATE FORM <br /> P ✓APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L {SEE ATTAC HENT WI1H CONDITIONS) <br /> A [PLAN REVIEWERS NAME --- --- -i --------------------- DATE __________ <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: '1 CERIIFY 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 BECOM <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 SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNEDDATE <br /> ---------------- - ---------------------------------------- --------------------------- <br /> OFFICE USE ONLY EN 13 016 !2/ss <br /> i sstssssstsssstsssasstssssssssssssisssssststssttssssstsssstssssssssssssssttsststsistsssssssssstsssssssttsssttssssstssstss <br /> SWEEPS 1 I COMP 1 ILOC CODE IDI ST CODEI AMOUNT DUE AMOUNT RCVD ' CKI/CASH RCVD BY D� ATE RCVD PERMIT 1 <br />