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9C. c1c. <br />t: APPLICATION FOR PERMIT . t• . LSAN JOAQUILN GLOCALk�HEALTH DISTRICT F <br />t: UNDERGR I D TANK t; 1601 E HAZELTON AVE., STOCK A t; <br />t: CLOSURE i ANDONMENT t; Telephone (209) 468-34 o) , <br />::. ft::f If.: P <br />w03,xrsx►s:rs:Fs:►s'::.. :� �s: �x�y:�r.�:::':.:s.':.'.:::s:u y�"" <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 ----- TEMPORARY CLOSURE ABANDONMENT IN PLACE 'WK -FS HEALTH <br />EPA SITE PROJECT CONTACT I TELEPHONE 1 l <br />G�P `r G r— 875c) <br />F FACILITY NAME {�ll1�T �i/l PHONE 1 <br />A ?(2q-1239- 61-203 <br />C ADDRESS 13-1 /y/ Aln/ QST. 1'% f✓ <br />lTCC "4 - w <br />L CROSS STREET /VORTH C�1-T /4y� <br />I <br />YOWNER/OPERATOR PHONE # 1g8 <br />UL�%�QTS <br />C CONTRACTOR NAME <br />O PHONE I a SZ�$-9�S3 r t�7IT/SEI`VIC�E �i..rt� <br />N CONTRACTOR ADDRESS c131LKD_ CA LIC 1 ggcj,{U CLASS <br />T <br />R INSURER�� WORK.COMP.1 <br />A -- - --- - - --- -- - _ _ _ <br />C FIRE DISTRICT i }'�> N T (° PERMIT 1/(NSPTR <br />T <br />RLABORATORY NAME �� L I, "A 76 � PHONE 1 `J �-� _ L O 6 Cp <br />SAMPLING FIRM) �`1 ( I , /9 TE A <br />1�Ilill�d�p¢VWUdy�DN�ill�uigl�l✓IV�Irur i u�tfi nn,i���mFurom �- � SAMPLING METHOD <br />T <br />TANK 10 1 <br />TANK SIZE <br />CHEMICALS STORED CURRENTL <br />CHEMICALS STORED PREVIOUSL <br />A 39- <br />/`� — -, <br />SCSQ <br />GAL, <br />�,` O S�� <br />Q )L <br />A <br />N 39-1�y <br />----=------ -�_ <br />000 <br />Gq 1... <br />UJIJL <br />-/A <br />K 39- --------------------------- <br />-- --- <br />39- <br />39---------------------------- <br />- <br />LIST ADDITIONAL <br />TANK INFORMATION AS <br />NEEDED ON SEPARATE FORM <br />U� <br />lI1M1�W8BIWUWI <br />NguWWlWuidi �.ugewilLl�nn�ixein��eiii <br />-I!{ <br />P <br />L <br />____ APPROVED <br />___APPROVED <br />WITH CONDITIONS ___ <br />pi uirivsnr� <br />DISAPPROVED <br />P <br />A LAN <br />REVIEWERS NAME <br />(SEE ATTACHMENT <br />WITH CONDITIONS) <br />N-------------------------------------------------------------- <br />DATE --»------------------------ <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: 'I CERTIFY THAT <br />IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <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 />CALF. FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br />SIGNED_ r�VFI_ - � rr� - 6'— <br />OFFICE USE 1fIY--fN 23 4 6^12188 "---' ----------------------------DATE_1 _-_ �____-- — — �_------- <br />sssstf;sssstitiss:sstistsssstsss: sts$$$$ sass::siimssstttssmi(isssstixsss(':sstsssssttsssssc $$m <br />SWEEPS COMP 11JLOC CODE JOIST CODE AMOUNT DUE f AMOUNT RCVD I CK1lCASH I RCVD BYI DATE RCVD I PERMIT 1 <br />