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ttt'tttt tt tt tt tt•tt trttrtttt tt•tt tt,tvatttt•tttt•tt tt trtt.tttt•- tt tray <br /> t: ArPLICA FOR PERMIT a SAN JOAQUIN LOCAL 11EAL1I TRICTu <br /> r UNG UND TANK 1601 E IIAIELTON AVE., ST 7 TOM CA t <br /> t: CLOSURE OR ABANDONMENT t. Telephone (209) 468-3420 <br /> t� <br /> t1ftt'tt'tt'tt'tt'tt'till t*t`►,�tt't?'t'.'t:?t tT t:'tT t.'t:'t*'►rr;tt:tt:►:'tt'!t t:'t:'t' <br /> ArPLICA110N EOR PERMAHENTITEMrORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTAIICES STORAGE FACILITY` }; <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE 1N ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW <br /> _l__ REMOVAL ----- TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br /> EPA SITE 11-0_4 <br /> C'_ Dom' /C7� � PROJECT CONTACT G TELEPHONE 1 /,�f, +/ — — <br /> F FACILITY NAME T.. !�/ f�' /��- i•�[.//,� <br /> A �� I7Z71 �1 T�1�Lfi J PHONE <br /> 1L� <br /> ADDRESS C <br /> L CROSS STREET <br /> 1 <br /> T OWNER/OPERATOR �} vA'� �► PHONE I <br /> C CONTRACTOR NAME ` x� �� PHONE 1 — +----•- <br /> N CONTRACTOR ADDRESS �- <br /> T —� ' d. �s r,2/ L` '1:f-, CA uc ICCAs <br /> R INSURER �N l <br /> WORK,COMP.1 e7 6�c��- <br /> A 5 <br /> 7 -_- _ -----� <br /> C FIRE DISTRICT/—) __._..__...__.�`__-.,....__.—.:`.• <br /> T .� �C PERMIT 11INSPTR <br /> R LABORATORY NAME <br /> !J PHONE 1 <br /> SAMPLING FIRIi+ SAMPLING METHOD <br /> — ;Na�enu�m4UrtDrAmmir�toa�uuBlT��mttt�mtnrt <br /> T .T —/ <br /> .TANK SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PR€VIOUSL <br /> N31 ---------------------------- <br /> K ]I- <br /> 39---------------------------- <br /> 9-i9---------------------------- <br /> 39--------------------------- <br /> — gQtIAtEID4+tf LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> 1TAA1M9i�UElilnOdl�t�,DtlIGI�l6tl�tiU9dQppla��p �ml11�I�lIOYIf�'�TllyypNGgOryl4TAGD <br /> mmom"��l <br /> L __ APPROVED APPROVED WITH CONDITIONS <br /> L - r (SEE ATTACHMENT WITH CONDITIONS?--- DISAPPROVED <br /> A PLAN REVIEWERS NAME <br /> N --------------------------------------------------------------DATE <br /> — q9!Gnl�l�I11tV1�+�'Jl9rtI�1TUG!�D �I�IUIDINl1ClItRY�ItNh�4lODU019p�1V7p�lAIIDI1�E� ---------»---------------- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOA4UIH COUNTY DRDINAIIC�EtS, STATE IJSAND pEg� AND ItREGULATIONS <br /> 4F THE SAN JOAAtIIN LOCAL NEALIH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINGI 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH 1111S PERMIT IS ISSUED, I SH►LL-NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO AECOM <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA,• CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFTES THE <br /> FOLLOWINGI '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 /> CALL FOR INSPECTIONS AT LEAST 4E3 HOURS IN ADVANCE <br /> SIGNED _ <br /> OEETCf-IISt ofir—IN116 17/19--- 1J-------------------------------------------------------------------DATE__ <br /> isfTsissisissssiiisssssssillsisis{iisisifisisssissssi N iiilitiiislliiiiiH siiiilsisii{itsffiT3t4ssiitsTsstllsssTiiissHi# <br /> SWEEPS -COMP 1- �Lt}C CODE JOIST CODE AMOUNT DUE AHQUHT RCVD CKIICASH RCVD 6Y DATE PCVU PERMIT I <br />