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.eu wec ec9 tt t{[F[{tt R IVa.ttt t.R n:tvas tv ti t,' 'tt,tl'ti, <br /> t APPLY N FOR PEkMIi t: SAN JOAQUIN LOCAL HEALi*TRICTt; <br /> t: UND ROUND TANK G 1601 E HAZELTON AVE., STOCK.TON CAt. <br /> F CLOSURE OR ABANDONMENT t; Telephone (209) 460-3420 <br /> -1.1..ffn n:.rnrn:0xn:t>:� :b :n:n, :, n:,:n:t>:n:�x n:t::.>: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 IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE I C <br /> (74)(1 j f PROJECT CONTACT 1 TELEPHONE 1 <br /> F FACILITY NAME � � ---- ~ - — <br /> A L PHONE 1 <br /> C ADDRESS _ <br /> 1 01 of <br /> L CROSS STREET <br /> 1 <br /> ILu- <br /> T OWNER/OPERATOR <br /> _Y -----�I /\ PHONE Y <br /> C CONTRACTOR NAME <br /> 0 O/utr- PHONE t 2� c3 <br /> N CONTRACTOR ADDRESS <br /> Ie old IFOg CA LIC 1 ,t7833 CLASS <br /> _ <br /> R INSURER <br /> A —- ----- - WORK,.COMP.1 ,,P 8(0l <br /> C FIRE DISTRICT — -- -- --...—`—_—QZ�, --- <br /> T C o S fGC. e� ,d, �, PERMIT 1/1NSPTR — -------- -- — -- <br /> 0 LABORATORY NAME —L S <br /> R FGL PHONE 1 20� <br /> SAMPLING FIRM* g3/'/2&(a <br /> IWNWMyUVNtlpp�lpum SAMPLING METHOD <br /> TANK 10 1 TANK SIZE T /- CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIDUSL <br /> A 39-_j (p( _ �----------- <br /> N E 39- ' <br /> --------------------------- ----- <br /> K 39-_ <br /> 39 <br /> - <br /> 39- - - ------------- <br /> ------------- ----------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P W7WWOtlVm�yytlpWpytDWtltlVVVOWWWOGVdNtlDWWYVOWYWVVWWYWVWWYYGWVWOtlWW pVVMtlVNVNdpVVWtlIWIIN <br /> L APPROVED _-_APPROVED WITH CONDITIONS DISAPPROVED <br /> A PLAN REVIEWERS NAME _ _ (SEE ATTACHMENT WiTH CONDITIONS) <br /> N � _ J <br /> APPLICANT MUST PERFORM ALL WORK iN ACCORDANCE Wl�g JOAQUIN COUNTORDINANCES, LAW , EGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FAND RULES AND OLLOWING,; <br /> IN iNE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 CERTIFIESiTHE1HAT <br /> FOLLOWING: •i CERTIFY THAT iN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 1SSUE0, i SHALL EMPLOY PERSONS SUBJEC <br /> iO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED / c. <br /> OfFEtE USE 0 Y--EH 11 ! "' Ld`,' <br /> --------------------------------DATE _ - <br /> titfiffffififffftffffftffiSfftffffffftfffffftfffff�fftfffffffffffffffffftfffiff{fftfffff tffffffiffffffffftftffiffffftfff <br /> SWEEPS 1 COMP 1 LOC CODE 01St CODE AMOUNT DUE AMOUNT RCVO CKI/CASH I RCVD BY DATE RCVD PERMIT 1 <br /> G / <br />