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- -; i <br /> fit it it it it t1iLp it m-ti: ii:4 <br /> IPPLICA71 I PERMIT r SAN JOIQUII LOCAL HEALTH 011alk: <br /> f UJOIRGRwoula ?Am( t: 1601 1 HIZRLTON Avg., STOCK At <br /> A. CLOSURE 01 IIINDOMMEMY r. Telephone (2031 468-1420 t <br /> t1t:11111t tytl:t1:11,it:tit:it:it:tv.it:it:makyly tra a n:it:a it:a it:it:it:it:it: 1q90 <br /> APPLICATION FOR PERMANENT/TRKPORIRT CLOSUII OR IBAIDONMENT 11 PLACE OF UNDERGROUND RAZIRDOUS SUBSTANCES STORAGE FA, <br /> THIS PERMIT EXPIRES 90 DAYS FROM INS APPROVAL D178- DO NOT 11178 11 111 SIIADII AREAS. INDICATE PERMIT TYPE jgLOj9RT1EA11J <br /> PRVICES <br /> REMOVAL ___ TEMPORARY CLOSURE — ABANDONMENT IN FLICK <br /> EPA sits IQ-(Ac,-c)0c) r] SL45 PROJECT CDIIICT A TELEPHONE I <br /> 2 <br /> da` ) <br /> F FACILITY NAME PHONE <br /> 620193 -Vya 0 <br /> A 64tA4 <br /> C ADDRESS <br /> L CROSS stilly <br /> ? OVKER/OPIRITOR Pool[ 'I <br /> E36 <br /> C CoNtRICTOR RINI PHONE I <br /> 0 — -20-7- (Fd,5- <br /> I CONTRACTOR ADDRESSC1 LIC 1 ?3 CLASS 1� <br /> 7 -- �j I <br /> R INSURERRLCOIPA <br /> A 101 r#1j9CA <br /> C FIRE DISTRICT PERMIT I/IISPIR <br /> I — 0 iTY -1-"PAC- <br /> 0 LABORATORY NAME 1— 4 PHONE 1.2�-5:2 r7-�OS<3 <br /> R — ONA FOkNIA, vXTEla-LXE> I <br /> SAMPLIIG FIRMA SRM SAMPLING METHOD <br /> 1 26 5 0 ptesarL.- <br /> 7 TASK ID I TIKK sill CHEMICALS STORRO CURREMILI CHEMICALS STORED PRSVIOUSL <br /> LIST ADDY I ONAL TANK INFORMATION AS IREDRD 01 SEPARATE FORM <br /> P 71PPROTRD WITH CONDITIONS DISAPPROVED <br /> L (SIR il;AcgxlkT Vito CONDITIONS) <br /> A PLAN RRYIEWRIS MANI <br /> Dill <br /> APPLICANT MUST PERFORM ALL WORK 11 ACCORDANCE Wilk SIN JOIOUIH COUNTY ORDINANCES, 3109 LAWS, AND RULES IND REGULATIONS <br /> OF THE SAN JOAOUII LOCAL HEALTH DISTRICT. DINER OR LICENSED IGEIIIS SIGI1IU11 CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE or THE YORK FOR WHICH THIS PERMIT 18 ISSUED, I SHALL 101 ENPLOI ANY PERSON IN SUCH HAMMER AS TO BECOM <br /> SUBJECT TO YORKER'S CONPINSITION LAYS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNIfURI CERTIFIES IRS <br /> FOLLOVING: 11 CERTIFY THAT 11 THE PERFORM/NCB OF VII 1011 FOR WHICH THIS PERMIT 13 ISSUED, I SHALL EMPLOY PERSONS SuBjEc <br /> TO YORKER'S COMPENSATION LITS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS- AT LEAST 40 HOURS IN ADVANCE <br /> SIGNED <br /> DATE 0 <br /> OFFICI USI ONLY-911 23 Off 12111 <br /> slasps 1 I COMP I I LOC CODE JOIST CODRI AMOUNT OUR I IMOUlf RCVO I CKI/CASR I RCID 81 I Dill RCVD I PERMIT I <br />