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t.aaL-17t#:tt:Lt:ftLt:Ct't't;'.tt�tt tt=t;-Ct tt: t�tt�arl:ftt1:R n:a:ffffatvv <br /> t: APPLICATI, FOR PERMIT t: SAN JOAQUIN LOCAL HEALTH D CTS <br /> t: UNDERRVO TANKt 1601 E HAIELTON AVE., STOCICAL. <br /> t: CLOSURE OR ABANDONMENT <br /> t: Telephone (209) 468-3420 <br /> }:h}:FJ:1}:FJ;i3:Y}:F}:ii:i?:F}:i}:F?:lJ:F?'. <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _ __ REMOVAL <br /> _1111 TEMPORARY CLOSURE ABA <br /> NDONMENT 1N PLACE <br /> EPA SITE # '1 --=—= ----- _--_ - <br /> �, PROJECT CONTACT !t TELEPHONE # p •r" lf �T" <br /> F FACILITY NAME � � r <br /> A PHONE # !/ <br /> C ADDRESS <br /> I 1 <br /> � <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR �- <br /> Y �� ' J� /'�'`/ PHONE 1 <br /> C CONTRACTOR NAME,,6/- - -. �r� PH-ONE I <br /> _ <br /> N CONTRACTOR ADDRESS�, �,�, C �� � � CA LIC #y� ''G' r <br /> T '' / '_ CLA5�_ <br /> P, INSURER <br /> A _ S - WORK.COMP. <br /> C FIRE DISTRICT �,��/ <br /> r PERMIT #/I NSPTR <br /> _ <br /> O LABORATORY NAME <br /> k <br /> SAMPL IMG FIRMSf«- <br /> IWmIIIIIaIlm SAMPLING METHOD <br /> TANK ID II TANK SIIE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> N 39-_ <br /> K 39- <br /> 39 <br /> 9 39 -- <br /> 39---------------------------- <br /> ------------ <br /> ------LI5T AD ZONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P � � <br /> L <br /> ---- <br /> APPROVED __APPROVED WITH CONDITIONS _ DISAPPROVED <br /> (SEE ATTACH T WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME �/� _ <br /> N -1111-_ -- 1111-- -------------- ---» DATE__ -Z-Z --------- <br /> jimmadvmIum <br /> fVllll9l�Il�tllf6NlIWfUIrXNIUp�1V#UQII�IiIIIV6�p16N 41ilXdll�9ll� IDIfI��p#llfOUll�l <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: 'ICERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER A5 TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF 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 SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED <br /> --- -------- -- --- 1i1i-OFFICE--USE-ONLY--ER-13-446-17/80---------------------------------------------------------DATE <br /> ---------------------1111-- <br /> fffffffffffffffffffffffffffffffffffffffffffffffiffffffffffffffffffffffffff#ffffffffffffffff#ffffffffffiffffffffffffffffff <br /> SWEEPS I COMP # ILOC CODE JOIST CODE f AMOUNT DUE AMOUNT RCVD CK#/CASH RCVD BY DATE RCUD PERMIT # <br />