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tt:! tfi tfi tt Mirtv.2 LI:as tt efi r tl:ti,tt R:n. t}:t tt till t}: <br /> r dPP6 Iog FOR PERMIT �: SIN JOAQUIN LOCAL HEALL ISri ICTt: <br /> F UNDERGROUND TANK r 1601 B N1IELTON AVE., STOCKTOW Cit: <br /> t: CLOSURE OR IBINDONMEIT r Telephone (209) 168-3120 <br /> e <br /> Gti: ti:tfi:tt t1:n. kfi:tfi:kfitt:ttt}:tfi:tt�Cfi:tt:tttfi:kt:tt:tt:tt:t}:t;:tt'kfi'tt'tt <br /> APPLICATION FOR PRRMANEKT/TEMPORARY CLOSURE OR ABIIDOHMENT 11 PLACE OF UNDERGROUND 81111DOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT eYPIRES 90 DAYS FROM THE APPROVAL SITE. DO NOT FRITS IN 111 SHADES AREAS. INDICATE PERMIT TYPE BELOW: <br /> }/ FIKOVAL _- TEMPORARY CLOSURE — ABANDONMENT IN PLICB <br /> EPA SITE I G "�C O Q 6 PROJECT CONTICT K TRLEPHONE/J" <br /> P P1C[LI1Y NAME PHONE I <br /> I�- . <br /> C IDDRess <br /> I .ADD o Ale. C/d. 2ga <br /> L CROSS STRAIT <br /> t 1,02 e <br /> T OWNER/OPee1TOR <br /> i PHONE <br /> C CONTRICTOR NAME T / _ PHONE 1 --- <br /> o h gel-��65 <br /> Y COYtRdC10R ADDRESS <br /> T CT CA LIC I�— S CLASS <br /> I INSURER L z Ja S <br /> A VORK.COMP.I LZ <br /> C FIRE DISTRICT �y��10 <br /> T PERMIT I/IISPTR <br /> 0 LABORATORY NAME C a <br /> R PHONE <br /> �c,ti �. 5-0 <br /> SIMPLING FIRM' <br /> Bre 44)y le SAMPLING METIOD S <br /> D I <br /> T TTNA [ ILIA SASE CHEMICALS STORED CURRFITL CHEMICILS STORED PREVIOUSL <br /> 1 <br /> Y J9 <br /> 1 39- <br /> 39- <br /> 13- <br /> LIST ADDIT[ONIL TANK IMFORHITION AS NEEDED of SEPARATE FORK <br /> WtlYdtlR 0R LLfd WLwpCx pkmax,mne =z"' <br /> P <br /> L __ APPROVED _APPROVED WITH CONDITIONS _ DISAPPROVED <br /> n 6}J <br /> (SEE /TTdCRMENT WITS COYDITIOYS) <br /> A PLAN REVIEWERS MIME 1 �af� <br /> Y DATE <br /> APPLICANT MUST PERFORM ALL WORK IN 1CCOHDdNCE WITH STN JOdQUIH COUNTY ORDININCES, STATE LAWS, IND RULES IND REGULITIOSS <br /> OF THE SIN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED IGENT'S SIGNATURE YC: 'I CERTIFY THAT <br /> CERTIFIES THE FOLLOWING:IN THE PERFORMINCE OF THE WORK FOR WHICH THIS PERMII IS ISSUED, I SHALL NOT. RMPN MANNER IS TO BECOM <br /> FOLLOWING: CER IFN PERSON IN OWI <br /> FOLLOW! TO YORKER'S COMPBISITfON LAWS OF CALIFORNIA ' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TNS <br /> TO YORKER'S'l CERTIFY THI1 Itl THE PERFORMANCE OF 111E YORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL EMPLOY PERSONS SUBJ,C <br /> TCOMPENSATION LAWS OF CILIFORI[I. <br /> CALL NSP C NS AT LEAST 48 PIOURS IN ADVANCE <br /> SICKED4USOb <br /> � <br /> OFFICIY-- II 13 016 11/EES <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS 1 COMP 1 I LOC COD, DIST COD AMOUNT DUE AMOUNT RCVD — CKI/CASA I RCVD BY DATE RCVD PERMIT <br />