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t: APPLICATION FOR PERMIT t: SAN JOAQUIN LOCAL HEALTH DISTRICT"t, <br /> r UNDERGROUND TANK r 1601 E HAZELTON AVE., STOCKTON CAt. / , <br /> t: CLOSURE O*ANDONMENT t; Telephone (209) 468-3420 k J blJ o <br /> r.!r :!t . !: . . n: ;n :!Ri :. ....n..1:nnx <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL _____ TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br /> EPA SITE t ( AC O O I -I / g05 PROJECT CONTACT t TELEPHONE 1 1 — <br /> b _ c �l l= l�vo�l 907 �r�y— <br /> F FACILITY NAME n I �T�S P <br /> A 1. HONE t 1�I rJ- S� 0 - I 0 LI 9053 <br /> I ADDRESS 6 5 E W A) �j Sir . 3r) e r—TG N. <br /> L CROSS STREET C'/42r,N� <br /> I �. <br /> T OWNER/OPERATOR PHONE f <br /> Y I--0 MER ASSoCI AT-ES _'-4I5- Syo - <br /> C CONTRACTOR NAME C b PHONE t r� <br /> N CONTRACTOR AODRESS1431 nAkAPc�-O CA LIC I tt. g Z� CL S3� <br /> T � I A <br /> R INSURER � 0 �� S WORK.COMP.1 <br /> C FIRE DISTRI <br /> T CT c� Y�f�ier� a PERMIT 1/INSPTR~ <br /> _ <br /> 0 LABORATORY NAME C ALT' F, W ATc (Z- �A C� PHONE 1 � <br /> R o� q - S27- y0-5lD <br /> SAMPLING FIRM+ /0-lA,,c. S��' t''r6s SAMPLING METHOD <br /> T TANK ID I TANK SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> A 39-- 2- 3o7-G1 650 G. S <br /> N 39 3p-Z--------------- <br /> K 131 <br /> --------------------------- <br /> 39 <br /> --------------------------- <br /> 39 <br /> --------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P APPROVED __ APPROVED WITH CONDITIONS ___ DISAPPROVED <br /> L /J S ATT NT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME /fz��i L{ <br /> �� - GATE-- �I�I <br /> N - <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: '1 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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: 11 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CAL FO INSPECT ONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED - n <br /> DfF1Cf U 0 Y--EH 13 016 71188 <br /> - - --DATE -------1-u-- <br /> fffffttfiffffifff{f{ffftffifffffiffffiffffff{ffffffffffffittffffffffftfffffffffftitfiftfftffffiffffffiftffffffffifftfffff <br /> SWEEPS t COMP 1 LOC CODE DTST CODE AMOUNT DUE AMOUNT RCVD CKI/CASH _REy��Y TE R VD PERMIT t <br /> 23% 7 'A °U <br /> W, dc) 1 1-3 I / IIJ <br />