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c� CY <br /> t.R:ti:R-ty" l tt*.tt:tfij-tk:tj:tj:tj.t:t'.tt.tk:ff.t:V.tV.t7g:t:r.fft:t.t4r.tfit3 tktk: <br /> APPLI(, .. FOR PERMIT t: SAN JOAQUIN LOCAL HEALTH-w�,RICT t: <br /> t: UNDERGROUND TANK t: 1601 E HAZELTON AVE., STOCKTON CA t: <br /> t: CLOSURE OR ABANDONMENT t: Telephone (209) 463-3420 t: <br /> r:r}:rs:rx►�:►�:►�:►y:n:n:►rr.►�:►s:►x.►x.►x►r:rs:rx►x.►y:rr.►}:r}:Fr................. <br /> .................................................................. <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> 4 REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME G�1� ,,�-7� G I PHONE # <br /> A --�— <br /> I ADDRESS ;,7GC) yj <br /> �PcM1I� <br /> L CROSS STREET G <br /> I <br /> T OWNER/OPERATOR PHONE <br /> C CONTRACTOR NAME O . , PHONE <br /> 0 <br /> N CONTRACTOR ADORES S ( G! CA LIC # /�7 p CLASS 6—1 <br /> T <br /> R INSURER � ��, ( �--' WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT #/INSPTR .— <br /> T G I v�- X 06 <br /> 0 LA80RATORY NAME PHONE # <br /> SAMPLING FIRMf �O G SAMPLING METHOD cjf4�ac ^� ���` p J off` <br /> fNTANK ID # TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSL <br /> --� -� _----=-1----------- O �L Dk <br /> , <br /> -----\l--= ----------- <br /> ------------,=----------- - <br /> ---------- <br /> i <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> APPROVED APPROVE➢ WITH CONDITIONS DISAPPROVED <br /> l -_ ---_- - EE ATTACHMENT WITH CONDITIONS) <br /> REVIEWERS NAME DATE <br /> ------------------------------- ----J/ -+ ------------- <br /> APPLICANT MUST 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: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: '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 /> CAL ,CALV FOR I/NSSPECT ONS AT LEAST 48 HOURS IN ADVANCE <br /> _ �C�.. _ <br /> SIGNED / - <br /> - ------- '' -------: ��=------------------------------------------------DATE-J----- --------- <br /> OFFICE USE ONLY--EH 73 0 /8 ! <br /> fiffffffffffffffiffffffffiffffiffffffffffffffffiffffifffffffffffff5ffffffffifffffffffff35f5fffffffffffffffffSffffffffffff <br /> SWEEPS # I COMP # LOC CODE JOIST CODEJ AMOUNT DUE I AMOUNT RCVD I CK#/CASH I RCVD BY I DA £ RCVD I PERMIT # <br />