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k kfi Nfi tfi Nfi kltfi kt kfifi bt L'l'L'2'l'fi kfi L'fi tt tfi kfi L'l R:ti:1:1:ki:1:1,ft tim A R:tl: �YJ,Y2 Q. <br /> - APPLICITIOB FOR PERMIT k: SAN JOAOUIN LOCAL HEALTH DISYRICT <br /> p: UNDERGROUND TANK p 1601 B HIZELTON AVE., STOCKTON CAT, 4 3 - 31/3Z <br /> p: CLOSURE OR ABANDONMENT p: Telephone (209) 168-3120 p: <br /> t kfi'!fi�L'fi�N4�tk�kfi�tfi�kfi'L'fi�L'1fi�l'fi�L'fi�tT�l'fi�Lfi�Nti L'fi�tk�4t L'i�tfi�Nfi�Nfi�kl�kfi�Nt�Nk�kfi�CE�kfi�kfi�kfi� <br /> APPLICATION FOR PRRMANEYT/TEMPORIRY CLOSURE OR IBAWDONMENT IN PLACE OF UNDERGROUND HAZIRDOUS SUBSTINCRS STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN 111 SOUND AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL --_ TRMPORARY CLOSURE — IBANDONMENT IN PLICS <br /> EPA SITE d 000 /a OPROJECT CONTIG} I TELEPHONE I <br /> F FICILITY NAME AtQ.r-kaQ ��Y S{f PHONE I — <br /> 1 ADDRESS you ��f h� v / SEo�kkO yL, CQ GSzA_ <br /> L CROSS STREET <br /> 1 <br /> T OWNERIOPERATOR PHONE I <br /> C CONTE/Cf OR MIME W n - -- PHONE I <br /> 0 l.lJ <br /> Y CONTRACTOR IDDRESS 0 CA LIC I ?0 CLISS <br /> R INSURER WORK.COP.I M <br /> _ _ _ Pc 99o��z <br /> C FIRE DISTRICT :. <br /> �7`1 <br /> T J yV i , /)Pt I PERMIT I/IMSPTR <br /> 0 LIBORATORY 111111 1t5l ,2✓ PHONE <br /> SIMPLIYC FIRM' �' _ '�Gn,J'ELde- 1SAMPLING METHOD <br /> -- IOIDIIUWUWWIIW�IIVUIIVINtlWI0111WDWYNWUIWVIWWWWVIWWIWl61 _ _ _ <br /> TANK 10 1 TAfNK SIZE CHRMICILS STORED CU;RR11TL CHRMICILS STORED PRBVIOUSL <br /> 1 39 _ 3 c1—Z_—_ Ll � `,_ hue be <br /> J9- -- <br /> 39- _ _ --- <br /> LIST ADDITIONAL TANK INFORMATION IS NBEDED ON SEPARATE FORK <br /> UOUVWVWOVVUWIWWUWWWWOWWWWUVDUUVVWtlWVWWVVI WWOWVWWIWVWIWWIUUIUWIWOUtlVWtlUVUVIIWIWIUUWIIVWVtltlVIINDVIIVWUWIItlURIIItlVUtlUWIWVVtlWUWUtl01WIWWWWtlVWUtlUUWUWWIWIIIWWWDWWWWWIIUWIWWV011VWUWNWUUWW <br /> p _ APPROVED IPPROVED WITH CONDITIONS DISAPPROVED <br /> L SBR 1TTACHMERt TH CONDITIONS) <br /> I PLAN REVIEWERS MIME BITE___ <br /> VIWYVWUIDWWNWIVWIWY�VYYWWIWIWWtlUVVVWHVVWIWWIIWUDVDWWUWIWIIWY VIWUDDWWVIOWIIWWVWWVIWVWWUWWWtlWWWVUWVWWWWIWIWYIUyWIIIWIIIIVYYUWWWWV100YUIWDWWW <br /> APPLICANT MUST PERFORM ILL RORK IN ACCORDANCE 11TH SIN JOIOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES IND REGULITIONS <br /> OF THE SIN JOAOUIN LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SIGNI?URB CERTIFIES THE FOLLOWING: 11 CBRTIFY THAT <br /> IN TUB PERFORMANCE OF THE WORK FOR WHICH TIAs PERMIT IS ISSUED, I SHALL NOT EMPLOY IVY PERSON IN SUCH MINMER 13 TO BECON <br /> SUBJECT 10 YORKER'S COMPENSITION LIES OF CALIFORNIA.' CONTRICTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THIT IN THE PERFORMIMCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSITION LBWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED _ DATE <br /> OFFICE USB ONLY-8i 17 016 11/81 <br /> --- --- -- <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS5SSSSSSSS <br /> SWEEPS Ij COMP I I LOC CODE-I DIST CODBI AMOUNT DUN AMOUNT RCVD I--CKI/CASA-I--RCVD-BY -I- 009 RCVD I--PERMIT <br />