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R:til:R:ttl*:V V 1:1 L LT:LI:Ll�LT:R:Rtl:tiv ti:t:t:LT:R:R-L-11:til:t-t:L'I :tj: <br /> APPLIC*" OR PERMIT It <br /> v SIM JO10UIM LOCAL REALTII wftNk; <br /> L. UNDERGROUND TANK L: 1601 E HAZELTOM AYE., STOCKTON CAL: <br /> CLOSURE OR ABANDONMENT t: Telephone (2091 468-3120 L a a ,, <br /> L�Llai.R.:LI:vv tl-:�v n:Lot:LIT:R!LT tl:t-1:ft ty L�j:k-t:4:�:Ly LT:LL LT:t:t:Ly Lj:Ly Lt a a.:a!ti-: 4 <br /> APPLICATION FOR PERMAMEMTJTEMPORARY CLOSURE OR ABkNDONHgX? IN PLACE OF UNDERGROUND HAZARDOUS SUBSTAXCE�AkEIFA609( <br /> THIS PERMIT 81PIRRS 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN III SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> FNVIRONMENTAL HEALT'' <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE DF-RMIT I SFPN'Ir- <br /> EPA SITE I JPROJECT CONTACT & TELEPHONE I <br /> ........... <br /> F FACILITY HARE PHONE 1 <br /> C ADDRESS <br /> 1 7 7 <br /> L CROSS STREET i:O <br /> T OWNER/OPERATOR 7,C, IVA/3 A PHONE I <br /> C CONTRACTOR RIME PHONE I <br /> 0 - <br /> M CONTRACTOR ADDRESS CA LIC I CLI <br /> 7 1...................-1.......... 4- <br /> R INSURER A <br /> WORK.COMP.1 <br /> C FIRE DISTRICT PERMIT I/1NSPTR <br /> 0 LABORATORY NAME PHONE I <br /> R —-------------- L—AR <br /> F <br /> SAMPLING FIRM' <br /> < SAMPLING <br /> ? TANK 10 1 TANK SIZE CHEMICALS STORED CURREMTLI CHEMICALS STORED PREVIOUSL <br /> K <br /> LIST ADDITIONAL TANK INFORXATIOX AS NEEDED ON SEPARIT9 FORK <br /> P APPROVED ROVED WITH CONDITIONS DISAPPROVED <br /> L —. <br /> 'SEE ITTACflKEXT WITH coxDjTjOjS <br /> A �ILII REVIEWERS 111, r <br /> 61 - <br /> DATE <br /> -- II111111I�IIVIlIIIIIiHI�IIIIIUIIIII✓HdIIIILIII�IHBII4IHIHII6IIIIHIIJIIIHIIIiIVHIIIGIIiIIIMIl0111H111�HIIdHllldlllillillllBBIIIIpIBIIIIBI111U1}ItIIbINHIfiHILlBllfllflilIIIIPII�IIIfiIH1111uIIHllllllllllfJ(llll�dllullllBtflIHIIIIIIfIINIGdIIBIIIIIfR�illflirlldHHHIHIIEI@lu�lblllVlilIIINIUIIPBIIYIHIIII3iN1116IISIIFRHIIIIiIII�HGIAI <br /> APPLICANT MUS? PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULITIONS11111 <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE FORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS To RECONI <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 ?119 YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS svBjgC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED <br /> OFFICE 12111 <br /> SWEEPS. I I COMP I LOC CODE JOIST CODE' AMOUNT DUR:__ I AMOUNT RcvO H RC7D BY DATE RcvD PERMIT I <br /> ............. <br /> ........... <br /> .——1--I. K <br />