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g:.`:::`«n.:«fi.d::ki`:;!} <br /> APPLICATION FOR PERMIT p SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> UNDERGXIANDONMENT <br /> TANK I601 E HAZELTON AVE., STOCKT&A g <br /> CLOSURE ;z TeIepliu (21A) 4GS-242 <br /> 1f�k�x�!S!1GJ#:f�«!ffff:«n:f;rN „�axg� S1c. off'�!f�f}fkif �if!flf!f:!if:f{fnS D <br /> APPLICATION FOP, PERMANENT/TEMPORARY CLOSURE OR AND IM111�1'1 P41AANUAH"ADED <br /> EGROUND'HAZAPDOUS SU .ES STORAGE FACI"THIS PERMIT EXPIRES 30 DAYS FROM THE APPROVAL DATE. DO NOT WRIAREAS. INDICAT PER%jj P2 qL*89 <br /> XREMOVAL -__-- TEMPORARY CLOSURE ---_ ABANDONMENT IN PLACE ENViRO�IVIFd7 +L HEALTH' <br /> EPA SITE t � PROJECT CONTACT & TELEPHONE t <br /> F FACILITY NAME PHONE 'C�°`�� L4(per-W2- <br /> A ' <br /> C ADDRESS q6j Z S7. tJE L 0 N VJ ``f ) ©Ci�`l G?N� (5A ' <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNERl$P€PMIN� �G�+uc� Gbl-L�N�- PHONE <br /> C CONTRACTOR NAME C��0��1D CONG%'1���+©�`1 �kJG + PHONE j�Sa-19 0 <br /> O <br /> H CONTRACTOR ADDRESS P,Q, e7OX ItZW -rotA..�g) (A•g3275 CA LIC t A-i4got CLASS <br /> T <br /> R INSUREF. I �};f�� I NSU Z. N `�y NORK.COMP.I <br /> A - - <br /> C FIRE DISTRICT,:�jfcr CIN 1 IM �l PERMIT 1/IN k,'IJ 1prPs� ia�',, <br /> 0 LABORATORY NAME (1,�,{�Q�I ��l6fti�f,�I�IC� G �II[ PHONE <br /> R <br /> SAMPLING FIRM- b" .Afftlyt. SAMPLING METHOD <br /> cl TANK 10 1 TANK SIZE ICHEMICALS STORED CURRENTLY CHEMICALS STORED PFREVIOUSLY <br /> T <br /> GS---------------------------- <br /> I-. <br /> 33- <br /> ---------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> .s yTq wnw�+wnM T4Y q I <br /> P APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L �(SEEEME,pi'T 1aITH ONDITI(INS) <br /> A PLAN REVIEWERS NAME DATE-------___l''-'_ - ---------------------- - -= _ - __-__----- <br /> -- - I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS,' AND-RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 01 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON`'IN SUCH MAN-REP AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS DF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT . LEAST 48 HOURS IN ADVANCE _______ ______ <br /> SIGNED -f- ------------ =�-��� ----'-------------------------DATE---f-- �J� -i----___.__ <br /> OFFICE IISE ONLY <br /> sssssss:sssssssssssssssssstsssssss4ssssssssssssssssssssssssssssssssssssssss:stssssssssssssssssssssssssssssssssssssssssssss <br /> SHEEP° 1 ' COMP t LOC CODE DUE AMOUNT PCVD CKI/CASH RCVD BY ' DATE P,CVO PERMIT t <br /> CODE 'DIST <br /> S S k 1--x'7=y 9 <br /> �p <br />