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't t�:an;tl*L:r. � t�-LT.tl:tx-t�'�l :ffti, ti: t TRICT <br />tfi tx:tl� <br />' w APPLIC N FOR PERKIT SAN JOAQUIN LOCAL HEILTH "t: <br />t: UNDERGROUWD 1191 t: 1601 E HAZELTON AVE., STOCKTOR Clt- <br />t: CLOSURE OR AIAMDONKENT t: Telephone (2091 468-3420 t: <br />" t�tx t� tx t� t�`t� tt t�t��ttx�t��tz t�t� t�t� tt�tZ�tx tz�t��tt�rx tx-tfi�tx�t��tzt��tx�tt'tt <br />APPLICATION FOR PERMANENT/TEMPORIRY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE, DO NOT YRITE IR III Sf11it)ED AREAS. INDICATE PERMIT TYPE BELOW: <br />1C REMOVAL_ TEMPORARY CLOSURE <br />ABANDONMENT IN PLACE <br />EPA SITE I <br />PROJECT CONTICT i TELEPHONE I a o g <br />� 4 l 98 <br />[ irk lips-� <br />F FACILITY RAKE <br />�. >/ G <br />s'Frs <br />PHONE I <br />I <br />C ADDRESS <br />�i9 Ly 57 jeo <br />1 <br />L CROSS STREETo a <br />I <br />T OWNER/OPERATOR <br />PHONE I <br />I kc,r <br />r lei s <br />PHONE I <br />C CONTRACTOR NIKE r <br />0 <br />II CONTRACTOR ADDRESS G <br />Cl LIC I S'G `�� � 4, CLASS <br />T <br />R INSURERC-,A e &/.,7i �� S <br />YORK,COMP.I t c y ��� <br />A <br />C FIRE DISTRICT <br />PERRI fANSPTR tr <br />T <br />0 LABORATORY RAKE�� <br />PHONE I <br />R <br />Q <br />SAMPLING FIRMt /c'l SAMPLING KETIOD <br />5 3 P 13'',d SS S,l� le <br />c 4 <br />TIME ID I TINT SIVE CHEMICILS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br />T <br />1 39- rah "/ _ C-42�G �dS <br />N 39-- ;� -_— —_4. 0 o c O e s E4 D S L �Sf <br />K 39- —3 o a 9 (f r- GA G G,4.s G G -1S <br />39- rr - !z a <br />31 - <br />LIST ADDITIONAL TANK INFORHATION AS NEEDED ON SEPARATE FORK <br />P IPPROVED APPROVED WITH CONDITIONS _ DISAPPROVED <br />L F� r <br />ATT OMEN? PITH CONDITIONS) ' f _ <br />Lt•l <br />I PLAN REVIEWERS HANE _ —DATE <br />N <br />APPLICANT MUST PERFORM ILL YORK IN ICCORDINCE WITH SAH JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES IND REGULITIOES <br />OF THE $11 10AQUIN LOCAL HEALTH DISTRICT, OWNER OR LICEISED IGEKT'S SIGNATURE CERTIFIES THE FOLLOV90 : 'I CERTIFY THAT <br />11 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MARKER AS TO BECOM <br />SUBJECT TO YORKER'S COMPENSATION LAYS OF CILIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: 'I CERTIFY ?HIT IN THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EKPLOY PERSONS SUBJEC <br />TO WORKER'S COMPENSATION LAWS OF CALIFORIII. <br />CALL FOR INSP CTIONS AT LEAST 48 FIOURS IN ADVANCE <br />SICKED____ le-k,DATE IG AUG_ <br />OFFICE <br />FFICEcc UpSEcc0MLCY 0[4.6 <br />(. (-r-(EU �a r23 C12181p <br />SWEEPS I1 COMP I L07 DIST CODI AMOUNT DUE AMOUNT RCVO CIII/CbSH RC9D ST J 011E RCVD PERMIT i <br />