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' lWti:ti:*It:R:ItIttittxIV.IT.IViktffItIt:It:R:I:9It:It:4:ti."ti.It <br /> IPPLICITIOI FOR PERMIT SII JOAQUIN LOCAL REILTN DISTRICTI: <br /> t UIDRRGROUND TINK t: 1601 B HIYBLT01 IVB., STOCKT01 CAT: <br /> t: CLOSURE OR IIINDOYNRIT Telep400e (209) 168-3124 t: <br /> t ti ti <br /> it!it: 2.0IT.tYLt.III.ati.Itti.ti,ati.tvIttvtyItR:N.n:A:0:IT.ti.ti'ti.N. <br /> APPLICATION FOR PRRMINBNT/TBMP01111 CLOSURE OR ABANDONMENT 11 PLACE OF UNDERGROUND 11111DOUS SUBSTAICES STORAGE FICILITI <br /> THIS PERMIT EXPIRES 90 DAYS FROM THB APPIOVIL DATE. DO NOT 11176 IN 111 SHID11 AREAS. INDICATE PERMIT TYPE IELOV: <br /> REMOVAL —_ TRMPORIRY CLOSURE — ABANDONMENT IN PLACE <br /> PROJECT CONTACT A TELEPHONE 1/' t SAF/ Cgci r <br /> EPI S111 1 .LO ,CSG / y-$—% 3 2 -3 r / <br /> P FACILITY MIME ES Ca/<. a Fir! SCS �/� 7•/-"c f PRONE 37 Zm <br /> 1 // s <br /> C ADDRESS /17( ��� k <br /> L CROSS STRNIT -� <br /> 1 <br /> T OWNER/OPERATOR PBOYB 1 27 <br /> -- <br /> C CONTRACTOR I►NBq u�l� ,N G��l q' �/ PHONE 190J - F7V- 37z.2 <br /> 0 <br /> I CORTRICTOR IDDRBSS�p h- 69C1 LIC Ij�2 /G Cuss <br /> I INSURE@SSG <br /> IORR.COMP.1 OG 5 ?y <br /> A — <br /> C FIRE DISTRICT06 gyp„ <br /> PERMIT 1/IISPTR <br /> 0 LABORATORY PIOY1 <br /> l.;2 ---2 <br /> r. <br /> SAMPLING FIRM' 5,9i-n-< q,5 /c /_ SINPLING METIOD <br /> TANK ID 1 TATE SISR CHEMICALS STORED CURIEITLI CHEMICALS Meet) PRRVIOUSL <br /> Tjo oc:n cS Oi �S� <br /> 1 39-_(1420 -01 -- <br /> N 39-_ <br /> K 39- <br /> 39- <br /> 39- <br /> LIST ADDITIONAL TIME INFORMATION 15 IEEDID OI SEPARATE FORI <br /> L7, <br /> 11YttlIWNWWYtlIwW11191Y_ APPROVED _APPROVED IITN CONDITIONS DISAPPROVED <br /> (SEB ITTICIN I IITN CORD TI01 —�_ �AME �. D1fE <br /> APPLICANT MUST PERFORM ILL 10 IN ICCORDINCE WITH SAN JOAQUIN COUYTY ORDINANCES, STATE L/VS, IND RULES IND REGULITIONS <br /> OP THE SAN JOAOUIV LOCAL RIALTO DISTRICT. OWNER OR LICENSED AGENT'S SIGNITURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> 11 THE PERFORMANCE OP THE 10119 FOR 1@ICH THIS PERMIT IS ISSUED, I SHALL NOT EXPLOT IVY PERSON IN SUCH MIYNBR IS TO BECOM <br /> SUBJECT TO YORKER'S COMPENSITION LIES OF CILIPORNIA.' CONTRACTOR'S HIRING OR SUECOITRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY THAT 11 THE PERFORMINCE OF TINE IORK FOR VNICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO YORKER'S COMPENSATION LITS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 90 HOURS IN ADVANCE <br /> SIGNED __ DATE <br /> OFFICE USE ONLY--BH 23 016 12/11 <br /> StSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSYSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSStSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS I I COMP I- I11 <br /> C CODE DIST CODB� AMOUNT DVB IMOUY} RCPD I CKIICISR RCID BT DI1R HCVD PERMIT <br />