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r•ta ta:r �ezta ea:exeaa to ta.eh:rzexrI to rata ra ra to to to HEAL :DISTRICT <br /> TRIC 61989 <br /> F APPLICATION FOR PERMIT a SAH JOIOUIK LOCAL HEALTH CKTON[elf. U C T `1 <br /> UKOBRGROUND 7111 t: 1601 8 AIZSLTOH INH., StOCK20N ,CIr: <br /> CLOSURE OR IIINDONMEIT t: ?elapSoat 0091 163-1120 r: INVIRONmEMALHEoa <br /> r ta:e:ra ra ra to ea to ra ttx ra to ra:to ra ra:to rY to to ea:to to ra ra to rn ra rata ray I'ERMIT/SERVICES <br /> IPPLICITION FOR PERMANERT/TBMPORIIT CLOSURE OR ABANDONMENT IM PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STOIIGE FACILITY <br /> THIS PERMIT RIPIRES 90 DAYS FROM THE APPROVAL 5179. DO NOT TRITE IN 111 SHADED AREAS. INDICATE PERMIT TYPE IEL09: <br /> ✓ RBMOWIL ^_ TEMPORARY CLOSURE — ABANDONMENT IN PLICS <br /> EPA SITE I C/&c✓ OOOZIO7,5 j PROJH"'T .. i TELEPHONE � IL� ROSL=LIDAFi L- <br /> F FACILITY MAKE JD Cil piNa2 �uzpoRONE 1 1_09 <br /> A ` / <br /> C ADDRESS .400 \fcSt �/At4PCC0 ROAn > TK'.Pcy , CIT53��v <br /> I <br /> L CROSS STIVIT <br /> I <br /> 1 OWNER/OPBHITOR PUGNE I 2_09 9'71 <br /> C CONTRACTOR NAME W A L-rnl EN 611N 1 nl PHONE I g I C, - g -7Z 1 Egg <br /> 0 - <br /> N CONTRACTOR IDDRRSS 031 Rts9C� L ANr' LIC S 5273Col CLASS -J5, c cQL <br /> T Cq CI <br /> R INSUR11 _?t -KeTr, i�oT-"0L_7_Z_ HU-W-PRY YORK.CONP.1 W5C� 3o8dit9ol <br /> A — — <br /> C FIRE DISTRICT I pL.r PERMIT I/IMSPT/ <br /> 1 <br /> 0 LABORATORY NAME AELgIS Gnlv1leo,.LpiENT1A PHONE 1 <br /> R <br /> HA-C> <br /> SAMPLINGPIIHI pkeC-A,.. <br /> � NVj2cbIftt-7JrpL SANPLINCNEtYOD m ss svr3� <br /> i�WIICiJWIWWWOWtlWWIWWI9WIIIIWIYtlIWWWWtlW7CIWWViDWE <br /> TANK ID I TINK SIZE CHENICILS STORED CURRESTL CHEMICILS STORED PRIVIOUSL <br /> TIR <br /> 10 00o tmL- NOK <br /> 174A <br /> J9- _ <br /> J9- <br /> LIST ADDITIONAL ?INK INFORHITIOM IS NEEDRD ON SEPARITE FORK <br /> !p,yJIIWIIVDWWP.�CIWt".VGJIWCD4111WWWWIdWWIWCdRWINJWWWWCI'IWI DtlIID17JIC.".d"WtIWWIIWItlIUuWR:WIS01WIi9WWWl�DIIWImWW0:9:J1!7;DGC9CL'WIICYY."J91LIW.�i72tltlWCWI'".Y�iWC:pWCWiIIpW:"Ji11111117tlY8WIJIWIIWItlCICWWW9WI71WIINYYIWDCTa;, <br /> p X IPPEOVED _IPPROVHD WITH COHDIIIONS _ DISAPPRO79D <br /> L / (SHB ITTACBMEP WITH COSDIV ONS) X=�v-411 PLAN REVIEWERS NIME �-/�— DATE --- <br /> K <br /> NtpYWKtl '"',LM.'"bBVRKIV&LBW" <br /> IPPLICINI MUST PERFORM ILL WORK IN ICCORDINCE WItH SIN JOAOUIN COUNTY ORDINANCES, STATE LAWS, IND RULES AND REGULATIONS <br /> OF THE SAN JOAOUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNITURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> IN THR PERPORNINCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON 11 SUCH MANNER 15 TO BECOM <br /> SUBJECT TO YORKER'S COMPENSIIION LITS OF CALIFORNIA.' CONTRICTOVS HIRING OR SUBCONTRACTING SIGMITU1E CERTIFIES THE <br /> FOLLOYING: 11 CERTIFY ?HIT 18 THE PERFORMANCE OF T11E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LITS OF CILIPORKIA. <br /> CALL FOR INSPE/CTIONS AT LEAST 40 IIOURS IN ADVANCE <br /> X� )-J <br /> SIGNED DATE /t <br /> �- '` _—___-- <br /> OFFICE USE ONLY-4H 6 12/11 <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS�SSSSSSSSSSSSSSSSSSSSSSSSSS3SSSSSSSSS <br /> SWEEPS I 'COMP I FLOC CODE OISTI AMOUNT DUE AM�RCVDL_CKI/CASH - D BY DI18 RCVD PERMIT I <br />