Laserfiche WebLink
at:MI:ki:t:�ft:ff III"R:M:M1.kt'kt.I kt:ktrkY knt:III.'ff I*ff R:R:MI:R:kt.kt'kt: <br /> g APPLICATION FOR PERMIT k. SAN JOAQUIN LOCAL HEALTH DIS CT k; <br /> k: UNDERG� TANK V. 1601 E HAIELTON AVE,, STOCY, Ak: <br /> f CLOSURE OMANDONMENT 1: Telephone (209) 468-3420 k: FgEaly <br /> 01�:1}}:1)'k:'1�'k:'1:'1:'1�'::'::'::: }aO:q:gaO:vXff1:'1}'ti:R: gAPPLICATION FOR PERMANENTHEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSSTAANCMARAG©rmakY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> ENVIRONMENTAL HEALTH <br /> _ REMOVAL _____ TEMPORARY CLOSURE ABANDONMENT 1N PLACE PERMIT/SERVICES <br /> EPA SITE i CAG OOO �S 6 S'd PROJECT CONTACT 6 TELEPHONE 16✓2s /c6 <br /> F FACILITY NAMEM S��L J CA L PHONE i /Z, % <br /> A l <br /> ADDRESS <br /> I 2LI2 VG .STdC IC <br /> L CROSS STREET <br /> I S T- <br /> T OWNER/OPERATOR PHONE f <br /> Y <br /> OC CONTRACTOR NAME PHONE i G�2 <br /> N CONTRACTOR ADDRESS CA LIC i CLASS�,_G _Q <br /> T <br /> A INSURER � s s��k ri c,4 S1es` WORK.COMP_i�� yyisS <br /> i <br /> C FIRE DISTRICT PERMIT i/INSPTR <br /> T O L -- <br /> 0 LABORATORY NAME r PHONE i <br /> fA <br /> ING FIRM* C SAMPLING METHO 71 <br /> Wafi�, <br /> TANK ID X TANK SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> 1 �� 1 E I— <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L EE ATTACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME ------ -> ----- - ---- -------------------DATE 7lg - <br /> N <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 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 SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED_..---__---_- DATE <br /> ---------------------------------------------------------------------- <br /> OffICE USE ONLY--EB 13 Ol6 11/88 <br /> ffffffffiffffffffffifffffftfffiffftfffffffiftffffiiffffitftffffftftffiffffffffffiffffftififfiiffftifffffifftfffifffff00 <br /> SWEEPS i COMP i LOC CODE DIST CODE AMOIINT DUE AMOUNT RCVD CKilCASH RCVD BY DATE RCVD PERMIT i <br />