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~ �� k tt kt ttkt kt tt tt tt tt tt tt tt=tt tt ti:ti:R:tt.It kir R:t R:ti: <br /> APPLICIT d FOR PERMIT k: SAM JOAQUIN LOCAL HEAL RICTk: PAYMENT <br /> t: UNDERGROUND TANK t: 1601 B HAZBLTON AVB,, STOCKTON CAt: <br /> t: CLOSURE OR 111INDONMENT t: Telephone 12091 468-3420 k: RECEIVED <br /> t tt tt R:rt:R.,R:fl:V.ftRI:tt�R:ft,tt:kt:kt:tt:tVR:R:tt-R:ki:R:ki ti:it:ktl,R:kt,ffti: DEC 1 5 1989 <br /> IPPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SU lltiTv <br /> TRIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DITB. -DO NOT YRITB IN III SHADED AREAS. IND �,' � d(�41$piM DivISION <br /> REMOVAL TEMPORARY CLOSURE _ ABANDONMENT IN ?LICE <br /> BPA SITE 100 PROJBC! CONIICT 6 TELEPHONE 1 <br /> F FACILITY NAME _[PHONE I .� 0, _ <br /> A -Z S2U l cc_7 Iw ' _ <br /> C ADDRESS <br /> I � j p�F L Gov — __-- <br /> L CROSS STREET <br /> 1 <br /> I OWNER/OPERATOR PHONE I <br /> rw <br /> C CONTRICTOR MAKE2 - PHONE I� --__-- <br /> ` P� J '��., �z.L) <br /> M CONTRACTOR ADDRESS �?7 CI LIC 1c�CI-� CUSS <br /> R INSURER pr�` ��2 WORK.COMP.1 r <br /> C FIRE DISTRICT L�, PERMIT I/IMSPTR <br /> R LABORATORY NAME ►-N �� � __ PHONE I2ZQ_1 , l3 <br /> SIMPLING FIRM= SAMPLING METHOD <br /> — +�/�Uamv <br /> ---TANK ID ITANK S17E CHEMICILS STORED CURRFNTL CHEMICALS STORED PRBVIOUSL�C73 9- LIST ADDITIONAL TANK INFORRATION IS NEEDED ON SEPARATE FORKWIII1kIIfIIIdWIGWdII;;INidi1111!ki!IU�JIJliIl111illllltiEWl«€kllN.il811d�°ldNilldk9il!"I$lilill!1�61lldlllfll!dll}II1aIWlULlipfldillGdlklddtllL'iIIIIAIIIdIIdIIGIU6idtIIIIIpLIIWI✓Ilfldldkd'i <br /> P —__ APPROVED _ 1PPROVBD WITH CONDITIONS DISAPPROVED <br /> L ISEE ITTACHHENT WITH COYDITIONSIf— <br /> A PLAN REVIEWBRS NAME <br /> N -- <br /> BWII�fIWIddRBWW WWRB INRIWAWI�NW8dR1RIIRWNIRIW8gWY8RdIdRWWIWV�fIRRdpIBRl8W8ff1WWfWYNW <br /> APPLICANT MUST PERFORM ALL YORK 11 ACCORDINCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES IND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE YORK FOR WHICH TRIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MINNER AS TO BECOM <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA,' COKTRICTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY MIT IN THE PERFORMANCE OF 111E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUDJEC <br /> TO WORKER'S COMPENSATION LIPS OF CALIFORRII. <br /> CALL FOR INSPECTIONS AT LEAST 48 FIOURS IN ADVANCE <br /> SIGNED -- I --��_ _---------------- DATE -_ <br /> OFFIC US ONLY- -` <br /> I z o46 iz/sI <br /> SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS$$SSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS1 COMP I LOC CODE D15! CODE' AMOUNT DUE AMOUNT RCVD CKI/CASH RCVD BY 0119 RCVD PERMIT <br />