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ttYt}trt}:t}:t}'etit ti:t}:ti:t}.t}:t}:t}:my.t}.at}:t}:t}:t}at}:t}.t1'. 1: <br /> APPLIC1110Y POR PERMIT r SIM JOIOUII LOCAL H61L <br /> tNppLICIllov fN DISt7ft: <br /> t UNDERGROUND TANI t 1601 B HIIELTON AVE., STOCCTOH Clt: <br /> r CLOSURE OR 1111DOMMENT t Telephone (2091 168-1120 t <br /> t t}i}:t}'t}:t}:t}:IV t}:g:t}}:t}ti:t}:t}:t}:t}t;:tt t}t}:t}:t}:t}:t;:t}:a t}t}:t}:t}:t}:a: <br /> APPLICATION FOR PERMANEIT/TEMPOIIRT CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HIIARDOUS SUBSTIYCES STORK¢ FACILITY <br /> THIS PERMIT BIPIIBS 90 DAYS THE APPROVAL DATE. DO NOT VII18 IN 111 SIIADBO AREAS. INDICATE PERMIT TYPE BELOW: <br /> r— EMOVIL ^_ TEMPORARY CLOSURE _ 1811DOMMENT IN PLACI <br /> EPA SITE 1 ( FXA a s y/ ROJBCt CONTACT A TELEPHONE I f/uhla o PKm <br /> /bc. �� 00019 08 /309) fr35 -3s 6 <br /> P FACILITY NINE C%v Qf E(p/pn PHONE I p X38 - 3ss6 <br /> I <br /> C ADDRESS P/03 tna07 St)-e, 2`J F5ralm, Ca, 9S3a0 <br /> L CROSS STISII <br /> 1 <br /> T OWNER/OPER/TORPHONE <br /> T ly Of Z--Ira/m <br /> C COYt11CT02 tlIM6 0;/ Equipment Srrui�r 'k"fh F'/j" PHONE 1 a09/ wq-1gog — <br /> 0 <br /> N CONTRACTOR ADDRESS 750 Jhcl4sfhal Way scnT J�k'aI, (a, C1 LIC 13a3�17 CLASS�61 4-0 <br /> t <br /> R INSURER (On Fle w4lY S Offre) YOIC.COMP.I 0;265-09'7 <br /> C FIRE OIStH(C* Cal. Iso�u orrrr' g,..twildN PBRMIt I/[YSPtR <br /> 0 LABORATORY MIME (-'p1irorni'a (Nakl' GADS PHONE I ;pq/ S;27- zl�-0S0 <br /> R TvH- So3o <br /> SIMPLING FIRM' (Sq)-e) SIMPLING METIOD grx e (froao) <br /> — auumWLu , TEPH 3550 3540 <br /> TANI ID I TAII SIZE CHEMICILS STORED CURRINTLI CHEMICILS STORED PRIVIOUSL <br /> Ta 0 a o - //on /✓0 c NVI Ey DE FUEL <br /> 1 J9--1-'j -QJ -- 00c) _ Tal/ E- /ESEL FUEL _ <br /> tl J9- Q - <br /> C 19- <br /> 15- <br /> LISTID ITIOMIL ?INK INFORMATION IS NEEDED OY SEPARATE PORN <br /> WIUNIWWItltWWNVVWWIWRIWWWIWRVRYYVWIVWWWIVVYItltl VYWiRWWWGRWDW11NIlYp11711111L" 411W14WW70WIWYWtIWtIIYtlWN19DWdWIIWitliIYJCIWWWWJWIYINIIIWIIW1'IWIIIIIWIIIWOWOIYWIIIpWWNdWVVWIIWIWIIL'W4IWJIIIIV@WIIWYtIWYL' <br /> P _ APPROVED _ IPPROVED WITH COHDITIOIIS DISAPPROVED <br /> L - (SEB ITTICOMEYT WITH CONDITIONS) <br /> 1 PLAN REVIEWERS YlMB n f — - D11E_�(13 1W --___- <br /> Y <br /> WYtlIWWtlYtlY0WWR8UV!0NDY0BWYYWWWWWIVBWRRRW0WI01WY0YI <br /> APPLICANT MUST PERFORM ILL WORK IN ACCORDANCE WITH SIM JOAOUIN COUNTY ORDINANCES, STITB LIPS, IND RULES IND REGULATIONS <br /> OF THE SIN JOAOUIN LOCAL NEILTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNITUR8 CERTIFIES THE FOLLOWING: 11 CERTIFY THIT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MINNER AS TO BECOM <br /> SUBJECT TO YORKER'S COMPENSITION LIPS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRhCTIWC SIGNATURE CERTIFIES 188 <br /> FOLLOWING: 11 CERTIFY THAT 11 THE P22FORKINCE OF THE NOR[ FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJEC <br /> TO YORKER'S COMPENSATION LIPS OF CILIFORYII. <br /> CALL FOR INSPE/CCTIONS AT LEAST 90 I-IOURS IN ADVANCE �/�� <br /> SIGNED- (!JE-fG ----- DATB�--�`-`=-L <br /> OFFICE USE ONLY--811 21 016 12/11 <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS!SSSS <br /> SWEEPS-i� COMP I I LOCCODE DIST CODB� IMOUMTcD�U6I AMOUWtcRCVD I ��fC�ASR RCVD B1- I BITS I PERMIT <br /> i`Rl —E 4*2( [- 6 326LZ7�>A--L------- — —jl--%j--=-1---- <br />