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nrr61wnIlun ruK rtKnII t: 5AN JUAUUIN LUCAL HEALTH DISTRICT <br /> UNDERGROi]ND TANK 1601E HAIELTOH AVE.,{STOCK^" CA <br /> t f1le— <br /> CLOSURE OANDONMENT Te)eplsone (209) 460-341k, <br /> �x:rxt ::•:.:►�:rxtix►s:r <br /> ■j:wplr..'x►s:Fa:W hxrt:�x�s:+s:►r.Ea:rx�rt�:r itx�s: �� <br /> r... Y■... .■Yr..... rr..........YY.......Y.....Y...........Y t - V <br /> APPLICATION FOR PERMANENUTEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FA <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DD NOT WRIT IN ; <br /> E ANY SHADED'AREAS.t INDICATE PERMI>z`rYPE MON: <br /> ZREMOVAL -- TEMPORARY CLOSURE __-- ABANDOA6T IN:;PLACE <br /> PITY <br /> SITE # �';Q:�U�193[�6 gPROJECT GONTAcr f TELEPHONE # IFCA <br /> F NAME �D'1 " y /� ! Im)r <br /> A PL)T-I4 3r'�fly& aPa� PHONE # ���� 5a`C <br /> C <br /> I ADDRESS 9157 <br /> L CROSS STREET <br /> I <br /> T 0, NNER/OPERATOR PHONE # <br /> Y eoT-H �wNG <br /> C CONTRACTOR NAME PHONE #.ate-!S Z4 4 S3 <br /> 0 � <br /> N CONTRACTOR ADDRESS y31 W. tA lea TNWQ9-0 CA LIC t <br /> T <br /> A INSURER ��5 WORK.COMP.# <br /> C FIRE DISTRICT A {� PERMIT #/INSPTR �e �� <br /> T G <br /> RO LABORATORY NAME �' A�g J PHONE i 5a�j _ yo <br /> 50 <br /> SAMPLING FIRM* ��LI F• WATER SAMPLING METHOD <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> A 39-___ p-'� - I V O o O �L l E 51~ L:( <br /> x 39- <br /> K 39----� -— --- 3 590 GAL W T O i -al/� a <br /> 39- ` y 1 5 o a G!L L_ -.EP%060 G S ` <br /> 39-_-- 0y� ,_ s 5o L ��� q <br /> LIST ADDITIONAL TANK INFORMATION AS HEEDED IN SEPARATE FORM <br /> P __ APPROVED APPROVED WITHffNDITIONS __'DISAPPROVED <br /> LN <br /> --- <br /> ( EY ATTAT CONDITIONS) <br /> EVIEWERS NAME <br /> ---------- -- - --- -- -=-------- ---------- ---DATE_-_._-- --------------------- <br /> ["N <br /> --- - ---------- <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 SALL 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: 21 CERTIFY THAT 11 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 /> F. <br /> CAL F R INSPECTIONS AT LEAST 43 HOURS IN ADVANCE <br /> SI6HED ----------------------------------- <br /> ca,, <br /> ` ------DATE_.7=-2.Z_:_�_L___---- <br /> OFFICE USE DNiY-- N 93 0#b 11198 ""--'--"-------`-------__ <br /> f;fffffff;tff;fff;ffffff;ffffffffiff;f##fffff;ffffff;fffff#ff;ffff;ff;;ff;f;f;fff#ffiffff#ffffffff;ffff;f;;fffffff;;ffff; <br /> SWEEPS 1 I COMP # LOC CODE DIST CODE AMOUNT DUE I AMOUNT RCVD CK#!CASH RCVD BY DATE RCVD PERMIT U <br /> ,1a d <br />