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• Gt}:t}:k}.ak}:t}:t}:t}};ti; Lt. ti: kvtt R:att.att.Nvet. atvatt.t9t;tvRt.tt <br />APPLIC11IOW FOR PERMIT a SAN JOIOUIN LOCAL HEALTH DISTRICTk: <br />t: UNDERGROUND TANK R: 1601 B H►ZRLTON APB., STOCKTON CA t: <br />t: CLOSURE OR IIINDONMINT k: Telephone 12091 168-3120 R <br />k:kt'tis tt: ft ti: kt ti: kt tI, kit t't: tlktwt;� till: ki: ff tis No R:t 111:141: tis tis tis R: ff kt its <br />APPLICATION FOR PERMANINT/TBMPORIR? CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br />THIS PERMIT EXPIRES 90 DIPS FROM THE APPROVAL DATE. DO NOT II179 IN 1111 SHADED AREAS. INDICITE PERMIT TYPE IBLOW: <br />v mRNOVIL TEMPORARY CLOSURE — /BINDONMBNT IN PLICE <br />BPA SITE I <br />PROJECT COPTIC? A TELEPHONE 1 <br />P <br />FACILITY MAMB C <br />PHONE 1 u1'.— els ��. b ,.d� 41 (k, <br />� <br />A <br />CplNADDRESS <br />r <br />�i5 c <br />I <br />L <br />CROSS STREET- <br />ON AC4 <br />1 <br />T <br />OYNBR/OPBRITOR C Jj ,,5C_ XQP,� pWN <br />PHOMB 1 <br />Y <br />ItEet�; i <br />C <br />CONTR/CTOR PIKE — — <br />PBONR 1 , <br />0 <br />Y <br />1 <br />CONTRACTOR ADDRESSCA <br />— --- /A 3 i U . %C7 <br />LIC 1 <br />IA�--- <br />CLASS <br />I <br />INSURER�t 1'--/1�L4 Ad _j 45LLA_A ✓c' YOflK.COMP.I F <br />C <br />PIRG DISTRICT �, j PERMIT I/IISPTR <br />0 <br />R <br />LIBORATORY YAMS, <br />CA1_11i=. WhlC-IZ LMM, <br />PRONE I <br />! :201 5af) W5 — - <br />SAMPLING FIRM' e�? A -nil l SAMPLING METYOD <br />YdtUYRWYYYYYNgNN — — <br />TINK ID I TAKK SIVE CHEMICALS STORED CURRINTLI CHEMICILS STORED PRIVIOUSL <br />f <br />9 3 OrJ s cPr� Cg5c L <br />A 39-�-- <br />— — <br />39- <br />K 39- — <br />— <br />39-- <br />— LIST ADDITIONIL ?ARK INFORMATION AS NEEDED OK SBPARITE PORK <br />WW�WtlYKIYNDYOWNWWYIWWWWNYDYYNYYYtlWWBNWIINY MWWgYDWWWWNOWYIlYW01wYWDWN!IWGYIYOIIYYWtlYYY.WWW01NYW3YNHYY9Y0YdDIDJtlL"'JUWiBIIYRItlNJIYJYYktlWOYWNYWONIWWWW00YWIWINOICIYYWIIN0YYY0WYW i <br />P APPROVED _IPPROVBD PITH CONDITIONS DISAPPROVED <br />L (SB IT70I1111T WITH CONDITIONS) <br />I <br />���--- <br />A PLAN RBVIEVIRS NINE ��Himilig <br />tl <br />APPLICANT MUST PERFORM ALL WORK IN ICCORDINCE WITH SIN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES IND REGULITIONS <br />OF THE SAN JOAQUIN LOCAL HBILTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNITURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br />IN TUB PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHILL NOT EMPLOY AMY PERSON IN SUCH MANNER AS TO BECOM <br />SUBJECT TO YORKER'S COMPENSATION LAPS OF CILIFORNIA.' CONTRICTOR'S HIRING OR SUBCONTRICTING SIGNITURB CERTIFIES THE <br />FOLLOWING: 'I CERTIFY THIT IN THE PERFORMANCE OF TIIB YORK FOR YHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br />TO PORKER'S COMPENSATION LAYS OF CILIPORNIL <br />CALL FOR INSPECTIONS AT LEAST 40 HOURS IN ADVANCE <br />SIGNED_f___ <br />OFFICE USE ONLY --III 23 Ol612%81 <br />SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br />SPBBPS I I CORP J ,LOC CODE]DIST CODE !MOUNT DURI AMOUNTCKI/CASH RCTD BY DATE RCVD— I PERMIT ( <br />Vl��""�I�� <br />13�e3 cA _ _t_— <br />1 1 <br />— <br />