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L:L t141:t :tfi'kt:tSt��:tt:tt:ti:t�tt:tT't2 tt tt:t2 tt:tt:L2:tt:N:tt t'�t:to tt:Lt: <br /> k APPLIC TON FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICTt: <br /> t: UNDERGROUND TINE t: 1601 E HAIELTON AVE., STOCKTON Clt: <br /> t: CLOSURE OR 18INDONNENT G telephone (2091 168-3120 t: <br /> ttrLx:ta:txta:ta:tt:ta:ta:L2t t�:tt tx:t�:Ll et:t:a tx tx:ta tt:et:tt:tt estt:ta:ta:ta:trta: <br /> APPLICATION FOR PERMANENT/TEMPORIRT CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND 91212DOUS SUBSTIKCES ST0210E FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT KEITH IN 111 SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL _— TEMPORARY CLOSURE ^ ABANDONMENT IN PLACE <br /> EPA SITE 1 PROJECT CONTICI i TELEPHONE p <br /> F FACILITY NAME <br /> e /� PHONE o - <br /> !a <br /> C ADDRESS <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE I <br /> c calrelcros NAxN PHONE I <br /> D c, C � 0 y�Ir- 12 l O a <br /> T COWt1dC10fl ADDRESS el <br /> CA LIC 1 S S CLASS <br /> A INSURER WORK.COMP.I <br /> P <br /> C FIRE DISTRICT PERMIT 11IHSPTR <br /> T <br /> 0 LABORATORY NAME / ��1 C �i 1,5 PHONE 120 p <br /> SdMPLItlG FIRM' T Y�` SAMPLING METRO0 <br /> oDx <br /> TANK ID I TAKE S11E CHEMICILS STORED CURREITL CHEMICALS STORED PREVIOUSL <br /> T G, <br /> Y 39 <br /> K 39- <br /> 39- <br /> 39- _ <br /> LIST ADDITIONAL TANK INFORMITION AS NEEDED 01 SEPARATE FORK <br /> 'NNOYgYHtlRNIY RiIpOlHpdgm m1' D�'I :ID'Ji101'"HJ.'� �JCKL^1CNfIRN�NYYI <br /> P APPROVED IPPROVED WITH CONDITIONS _ DISIPPROVED <br /> L (S "TTICHNENT WJTN CONDITIONS) <br /> I PLAN REVIEWERS WARE f` � ( DILE <br /> N <br /> APPLICANT MUST PERFORM ILL WORK IN ACCORDANCE VITO $18 JOAQUIN COUNTY ORDINANCES, STATE LIVS, 110 RULES LED REGULITIONS <br /> OF TUE Sig JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> 11 THE PERFORMINCE OF THE VORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY IVY PERSON IM SUCH MIXNER IS TO DECOR <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S RARING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, l SHALL EMPLOY PERSOKS SUBJEC <br /> TO ROOKER'S COMPENSATION LAWS OF CILIFORNII. <br /> CALL OR SP I AT LEAST 40 HOURS IN ADVANCE c� <br /> SIGHED DATE <br /> OFFICE USE ONLY--BH 13 016 12/II <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS IICORP I LOC CODE DIST COD AMOUNT DUE AMOUNT 1CVD CK1/CASH RCVD 11 DATE RCVD PERMIT I <br /> l�1 ty��r� � 3aa. S <br />