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` t tt ti:&IVtt ti:it, tett et IV%I:et att ti:tt it.t"I: it.t£Ef to t:it to tfi <br /> w APPLICITIOY FOR PERMIT w SAN JOIGUIM LOCAL HEALTH DISTRICT,: PAYMENT <br /> I; UNDERGROUND TAME 1; 1601 B HAXELTOM AVB., STOCKTON CAI: R E C E1 V E D <br /> I: CLOSURE OR ABANDONMENT I: telephone (209) 168-7120 t: <br /> I.t1:111 it:it.ti:it*tyR:It:tit IV tt IV it:tv tt'R:Ito tt.tt.ma tt a 11:Tutt tt it:Tutt:it: .AUG <br /> APPLICATION FOR PBRMANEYT/TBMPORIRY CLOSURE OR IBINDONNfNT IN PLACE OF UNDERGROUND NISIRD �� tIYCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE IPPROVIL DITH. DO NOT WRITE IN III SIRDBD AREAS. <br /> 1 CA Ylt6 w�1N rH <br /> r.^,Ir/sswlcFs <br /> — REMOVAL __ TEMPORARY CLOSURE — IBANDONMENT IN PLICE <br /> LPA SITE 1 �0�� PROJECT COMtICT I TELEPHONE I — <br /> P FACILITY MIME PHONE 1 <br /> I IDDRBS9 a O <br /> L CROSS STREET � <br /> fOYNBR/OPBRITOR PHONE I <br /> T <br /> C CONtRICtOR NIMB � - —� --- PtlONB 1-- - _====-TY•=-==-_•_ <br /> 0 <br /> N CONTRICTOR IDDRESS CA LIC I CLISS <br /> T <br /> R INSURER YORK.COXP.l -- <br /> C P1R8 DISTRICT PERMIT I/IWSPTR <br /> f <br /> 0 LABORITORY NIM& J, N O'rlln PHONE I <br /> SIMPLING FIRM' SIMPLING METHOD — <br /> mgYNDYmmmRDmhmR <br /> TAN[ ID 1 TIME Slle CHEMICILS STORED CURRENTL CHEMICALS STORED PREVIOOSL <br /> T <br /> 79-- - <br /> - LIST IDDITIONAL TANK INFORNITION AS NEEDED OY S[PAIITE FORM <br /> � mmDmN'JmImmDR�mIR91mDmYmtlYYYOmIWmlmmDimmDIIDtlIJGDD'JimmNDmItlD6DNtlIDtND9mRNmmDWYmmmtlmDlmdDWmmDDmDImD6lmmmDmmNmYW ' <br /> P -- APPROVED _1PPROPBD WITH CONDITIONS _ DISAPPROVED <br /> L (SEB 1TTICHMENT WITH CONDITIONS) <br /> A PLIN REVIEWERS NAME — DA16 <br /> M <br /> P <br /> --- -- ------ --------------- <br /> mDmDRUDNmRmmwmmmD�u�RmumimuawwmmmuDDmmmmI 1w <br /> IPPLICANT MUST PERFORM ILL WORK IN ACCORDINCE WITH SIM JOAQUIN COUNTY ORDIMANCES, STITE LIPS, AND RULES IND REGULITIOHS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMIACS OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHILL NOT EMPLOY AMY PERSON IN SUCH M1MM8R IS f0 BECON <br /> SUBJECt TO YORKER'S COMPENSATION LIWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: '1 CERTIFY ?NIT IN THE PERFORMINCB OF ?UK NOR[ FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO YORKER'S COMPENS/TION LIVS OF CILIFORNII. <br /> CALL FOR INSPECTIONS AT LEAST 40 HOURS IN ADVANCE <br /> SIGNED _ DATE <br /> OFFICE USK ONLY-411 23 016 11/11 -- ---' ----- <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSYSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSs'SSSSSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSS <br /> SYBEPS-1 -COMP I- I—LOC CODE I DIST CODE, NMI DUB - icYT R�CV�D I- CQV/2C2�� RCI � DA}g RCVD -I- PERMIT I - <br />