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APPLICATIOR PERMIT SAN JOAQUIN LOCAL HEALTH DlswkTt UNDERGRIW TANK 1601 E HAZELTON AVE., STOCKT13420 W k: - CLOSURE OR ABANDONMENT Telephone (209) 468 toff� ft b ............................................. ...... APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES WAGE RCH? THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE IiEALTH PERMIT 1 SERVICES REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE EPA SITE I Doo 115�6 PROJECT CONTACT & TELEPHONE I We34ztehi 10,4-e* vtai F FACILITY NAME —FHONE # qg(a _6 t2 4 A C ADDRESS I a3.2- L CROSS STREET I — I OWNER/OPERATOR PHONE It Y -PDM S162 4lay- 1-1600 70 - C CONTRACTOR NAME PHONE I 0 IN CONTRACTOR ADDRESS &!c,7 Zal CA LIC I CLASS C R INSURER WORK.COMP. A C FIRE DISTRICT PERMIT #/INSPTR B LABORATORY MAKE R d4t Aga, PHONE 1 —e06 g SAMPLING FIRM* 4,fjn-a,�- 6e- 2- SAMPLf HOD (/v �a 5-41�6- WT 1�( Al�. T TANK ID i TANK SIZE CHEMICALS STORED CURRENTLI CHEMICALS STORED PRE'VIOUSL) A S�� -- ................. IN 39 K39- ------------------- 1 ---- 39- --------------------------- -------------------------- 39- 9---------------------------- TANK 1111 T C ........ wkwwwwwwo ...................... ------- --------------------------- K M '9--------------------------- LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM APPROVED ---- VPPROVED WITH CONDITIONS ---- DISAPPROVED L "Og ((SEE ATTACH KITH CONDITIONS) A PLAN tREVIEWERS NA IN A PLAN REVIEWERS NAME e < DATE . ........... N ----------------- -- ------------------7---------------------DATE--- ------------------- ---- APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOMI SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING! 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC1 TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE S16MED DATE --------------------------------------------------------- ------- ----------- - - OffICE USE ONLY--EN 13 #l8 12/88 fffffffffffffffffffffffffffffffffffffffffffffffffffffffiffffffffifffffffffffffffffffffffffffffffffffffffff SWEEPS # I COMP I 1LOC CODE IDIST CODEJ AMOUNT DUE I AMOUNT RCVD CK#/CASH.J..RCVD BY __t DATE RCVD I PERMIT 3