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m <br />t tt 1'1: teto tt tt ttttt ttt.V LI: tt tt L't tt ti tttt tt tt Lett tt tt to tt tt tt <br />APPLICItIOW FOR PERMIT h: SAN JOIQUIY LOCAL HEALTH DISTRICT L: <br />t: UNDERGROUND TANK t: 1601 E HIZELTOW ARE., STOCKTON CIt:ID�I�I:��L1 IOJ <br />t. CLOSURE OR IBINOONMENT t: Telephone (209) 168-7120 t. <br />rft: t1ttttatttti: tttttttttttttta: ti: ttti: tt:Ltttti, tttttttt:9ttttttttttttt OCT 031989 <br />ES <br />THISIPERMITN EXPIRESM50EDAYSEFROMITHEGAPPROVALRDIT8KDODOENOTIWRITE INOIIINSeADKDUAREAS. INDICAN dP�f2MI1Tt'S't�l 1�E5'��HY <br />REMOVAL TEMPORARY CLOSURE — ABANDONMENT IN FLAGS <br />EPA SITE ^t (-A(:006�S <br />OOO ���d <br />-- _- - <br />PR OJECT CONTACT A TELEPHONE I-1111 <br />�— <br />PIIOH¢ 120-; f jQ�j <br />F <br />FACILITY NAME Lodi Cor1CretC f ���eSevv ce <br />-J <br />C <br />I <br />ADDRESS 39 V� Y >> <br />L <br />CROSS STREIT <br />1 <br />/ <br />PH RE I <br />1 <br />OWNER/OPERATOR <br />/ <br />C <br />COKtRICTOR YAMS— Se I PHONE 1 <br />0 <br />Y <br />CONTRACTOR ADDRESS (� /� <br />AVC <br />CI LIC 1 --_- <br />CLASS <br />R <br />, <br />INSURER <br />VORK.COMP.I <br />C <br />FIRE DISTRICT <br />PERMIT 1/[NSPTR <br />1 <br />0 <br />-- <br />LABORATORY YIMB �e�SO� I �zIO. CFGI-� <br />PHONE 1 <br />R p (- <br />SAMPLING FIRM# SAMPLING METIOG *q,Rr $C�1(l�1{L * I tt64 <br />— - <br />TANK ID I TANK SIZE CHEMICALS STORED CURRENTL CHEMICILS STORED PREVIOUST <br />3? (53LISTAL <br />I <br />TINK IMFORNITION IS NEEDED ON SEPARATE FORK <br />WIOWWIWR IWKtlIWLtlWNWIRWIWWWYWNWYWHW8IHIYOLHJWWIp <br />IPPROVED WITH COSDITIONS—DISAPPROVED <br />�PROVEE�DD-� (�_ <br />L�SIB A CIIMINt Y[TN OHDITICYS) <br />A PLAN REVIEWERS MIME <br />Y <br />WIWWWBRYWRYWY01111NWYWWY�WYdYYtl�WIIG IgWWIWWWWYWIIItlIWYIIIWINIWIWHWtlWWWtlP1lYWI�IIYWNWtlWOWW�UIIYNIIDWWYIYWNWtlWWYYWHW <br />APPLICANT MUST PERFORM ILL WORK IN ACCORDANCE WITH SAN JOIQUIN COUNTY ORDINANCES, STATE LAYS, AND RULES IND REGULATIONS <br />OF THE SAY JOAOUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT <br />IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL 10T EMPLOY ANY PERSON IN SUCH MIWNER AS TO BECOM <br />SUBJECT TO YORKER'S COMPENSATION LAYS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES IHR <br />FOLLOWING: 11 CERTIFY THAT IN THE PERFORMANCE OF 1HE YORK FOR WHICH THIS PERMIT IS ISSUED, I SIIALL EMPLOY PERSONS SUOJEC <br />TO YORKER'S COMPENSATION LAWS OF CILIFORNIY. <br />CALL FOR INSPECTIONS AT LEAST 48 IIOURS IN ADVANCE <br />i <br />SIGNED_ `r) I L -L <br />--------------DATE-I <br />OFFICE USE ONLY -411 016 12/11 �— T— <br />SSSSSSS4SSSSDSSSSSSSSSSSSSSSSSSSSS3SSS39�SS O4SSSSSSSSSSSSSSISSSSSSS6SSSSS3:SSSSS6SSSSSSSSSSGSSS9SSSSSSSSSSSSS95SSSSISSSS <br />SWEEPS I -COMP I- LOC CODE] DIST CODE (MOUNT DUE AMOUNT RCVD CKI/CASH -I- RCVD BY -�- DATE RCVD -]- PERMIT <br />