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` rtvty-1111 ttltrtvtink .tt:tvtbtt:ttmti.tt.tt.tvkiltvtbtXtvatZtLti� <br /> IPPLICIVOI FOR PERMIT r SIN JOIQUIN LOCAL HEALTH DISINICTr <br /> !: UNDERGROUND TIN[ r 1101 B HAYBL?0N IVB., S?OCK?01 Clr <br /> r CLOSURE OR 1111DONMIIT r Telephale (209) 161-1121 t: <br /> r kt ti tt tY 02 tt tl tt tt Gti�tt t;tt ti tfi tt kt tT tt tk ti!t ti'Itfl1 tt tt kt ks ti tt k1� <br /> APPLICATION FOR PERMANENT/TBMPORIRY CLOSUII OR ABIIDONMENT IN PLACE OF UNDERGROUND IIYIRDOUS SUBSTIICES STOIAGE FACILITY <br /> THIS PERMIT BIPIIBS 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN 111 SHADII AREAS. INDICATE PERMIT TYPE IILOW: <br /> REMOTIL _ TEMPORARY CLOSURE — ABANDONMENT IN PLACE <br /> BPA SITE PROJECT CONTICT A TELEPHONE I <br /> F FACILITY NAME S1 4 1 Lg PHONE I U� <br /> 1 <br /> L C ps RItT <br /> 1 <br /> T OWNER/OPBRITOR PHONE <br /> _ adry6 - - <br /> C CONTRACTOR MINI C PHONE Io _ 3 _ A0 Or <br /> 0 <br /> I CONTRACTOR ADDRESSU f / CA LIC I CLASS <br /> T <br /> sa <br /> R INSURER WOR[.COMPA <br /> C FIRE DISTRICT '� or PERMIT I/IMSPTR <br /> T <br /> 0 LABORATORY MIME3>/O�w <br /> R <br /> SAMPLING FIRM' ,, p Svc SINP611C METYOD r S >u� <br /> NtlCGYNNWWNYtlWRWRtlWItNI <br /> TANK ID 1 TANK Sill CHEMICALS STORED CURRENTLI CHEMICILS STORED PRK'VIOUSL <br /> 33-T <br /> 1 D ��3 <br /> K )9 tj <br /> �_3 O 03 <br /> J9- -- <br /> -- — LIST ADDITIONAL TANK INFORHITI01 IS NEEDED ON SEPARATE FORM <br /> tltlWW1RWYtltltltlYNNNIWWWYWWUYYWNYWNRtWYRWW Y1IRNNNHWNWIWIWtlIIwNtY" Y <br /> UWWWWWWLYRW!JtlWWWNilGWYl1JDLBWJIIY4IUWUItlMUY9Y@IUNURWU7WiuUYWWdYIIYUWBUIICWWWJIUNWWYWUWL <br /> P APPROVED _ PPROVBD WITH CONDITIONS _ DISAPPROVED <br /> L BE ATTACHMENT WITH CONDITIQYSI <br /> I PLAN REVIEWERS NIMB <br /> Y <br /> NMYItl�WII YNWYNN�tlNNWWNR11H8WtldYl <br /> IPPLICANT MUST PERFORM ALL WORK 11 ACCORDANCE WITH SAN JOIQUIN COUNTY ORDINANCES, STITH LIWS, AND RULES AND REGULITIOHS <br /> OF THE SAY JOAQUIN LOCAL HEALTH DISTRICT. OFHEI OR LICEYSID AGENT'S SIGNITURR CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> 11 THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH HAMMER IS TO BECOM <br /> SUBJECT TO YORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRICTOVS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: '1 CERTIFY ?HIT 11 THE PERFORMANCE OF ?116 1011 FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJEC <br /> TO YORKER'S COMPENSATION L11S OF CILIPORWII. <br /> CALL OR INSPECTIONS AT LEAST 40 HOURS IN ADVANCE <br /> SIGNED trJ DATE, �� 1 <br /> OFPIC U YLY--811 1J 016 12/11 <br /> SSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSYSSSSSSSSSSSSSS�iSSSSSSSSSSSSSSSSSs'SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS I -COMP I I LOC CODE I DIST COD BI—IMOUNT DUB _ AMOUNT RCVD I CKI/CISH'I— RCYO BY—I— DITB RCVD I PERMIT 1 - <br />