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•.• a ••• • ■•• ••urx�a.rxrrrYWwr�: ••ur• ••.••nrxGE, <br /> APPLICATION FOR PERMANENT/TEMPORARY CLO, OR ABANDONMENT IN PLACE OF UNDERGROUND HAI US SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 30 DAYS FROM THE APPROVAL DATE. 00 HOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _REMOVAL TEMPORARY CLOSURE - ABANDOHIiENT .IN PLACE <br /> f EPA SITE 1 e� U�1 93 9 6 8 PROJECT CONTACT i TELEPHONE # ) ' <br /> I {N441�0 �'YYi L:rbhJ <br /> F FACILITY NAME gon C .,.NG Qj„P6z,� PHONE 1 a 0 9= 6g L��b sj 3 <br /> A d'1 VvU r�`'v ' <br /> C ADDRESS 9157 <br /> L CROSS STREET QI R�. Rio A p <br /> I I ! <br /> T 0`WNER/OPERATOR PHONE # iia <br /> Y CUTS-{ N G <br /> 99 <br /> C CONTRACTOR NAME PHONE 1 <br /> N CONTRACTOR ADDRESS 1431 W. JA c\ j-y14)6eG-j,0 CA LIC ILl CLASS <br /> T <br /> A INSURER ��\(�'c`( Y�� WORK.COMP.1 6���� <br /> �'C�S + <br /> a C FIRE DISTRICT <br /> T A PERMIT 1/INSPTR <br /> RLABORATORY NAME Q)�L l;� � PHONE i 5a� yo D <br /> SAMPLING FIRM+ CA LI SAMPLING METHOD <br /> TANK ID # JANK SIZE CHEMICALSOREO CUf EHTL CHEMICALS STORED PREVIOUSL <br /> A 39GS`7 _ L � e�t <br /> J N 39--------------------------- �r <br /> K 39- ±r <br /> 33 <br /> 39--------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P �__ APPROVED ---APPROVED WITH CONDITIONS ....''`°DISAPPROVED <br /> L (SEE ATTACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME <br /> N ---------------------------------------------------------------DATE-•-----------------------...� <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: -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 ISSUEDtA SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CA OR INSP CTI;O S AT LEAST 48 HOURS hN ADVANCE <br /> SIGNED__ ..- -- DA _ _ <br /> OFFICE USF lfLY--fN 13 4/b 11198 -" ------------------"------------_ ----- TE <br /> tstssstttstsstssttftt�sssststtssstttst(i�tsstttttststttsttstttttsststttsssststtssstttttsstssstttsssssssssssststsssttsstsss <br /> SWEEPS # COMP # ILOC CODE IDI5T CODE AMOUNT DUE AMOUNT RCVD CK#lCASN RCVD BY DATE RCVD PERMIT 1 <br /> i <br />