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• r r�t��t�.�.�r��t��t��t��r��tt�t��t?rt��t��e��t1:�t;�tz�t��t��t��tt�tx�t�,:4.rt�c;�t��t�� <br /> APPLICITION FOR PERMIT k: SIN JOAQUIN LOCAL HEILfH DISTRICTt: <br /> t: UNDERGROUND TANK t: 1601 E HAZELTON AVE., STOCKTON Cit: ' Z w <br /> t: CLOSURE OR ISINDONMENT t: Telephone (109) 168-3120 t::__ <br /> lt2t�k�tit�ttr�t�'tlt�ktltit�t�t�t�t;tZtt;ti'tZt3txt�rtirt;r�txtzt�. ,i-.C;,t�� <br /> APPLICATION FOR PBRMIMENT/TEMPORARY CLOSURE OR IBINDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORIGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DITS. DO NOT 11I7E IN 111 SIIADYD AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL _____ TEMPORARY CLOSURE _ ABANDONMENT IN PLIC: <br /> EPA SITE 1 PROJECT CONTICT i TELEPHONE I �` <br /> kGoo5� o - azo3 <br /> F FACILITY NAME �� � �(� C,. PHONE I <br /> I _ <br /> ADDRESS �Z, -��1-�� S I • ������ <br /> L CROSS ST Y1 <br /> I 1-V►• <br /> T OWNER/OPERATOR �� ` S PHONE I <br /> 1 al /►+airy —SviTE Ob '2i°� • -74 L4 - �vv;r1 <br /> C CONTRICTOR NAME PHONE��� C�C�?�S\2vcTiOr.1 PHONE 1 <br /> 0 <br /> N CONTRICTOR ADDRESS l,2 E Z.Z ff��v J` CA LIC I � ��© CLASS A <br /> T <br /> R INSURER 4�4,0 f-P&-A- YORK.COMP.IuJCNgdZf Io <br /> C FIRE DISTRICT `L-r0 PERMIT 1/INSPTR <br /> 1 <br /> 0 LABORATORY NIM& 6 vl(LON � PHONE 1 G`ib - 3-7 • -(-�Lb <br /> R <br /> SAMPLING FIRMS ,q t. c6 IMPLIMG Mei10D -T P. B T. E X <br /> DWG�IYUIWUWlIYJWYN11WlitUUIDWDIYIYIDYD�WGL'9llIYYRYiIIWYgllYI — — — <br /> TANK ID I TINX 5129 CHEMICALS STORED CURREITLI CHEMICILS STORED PREM OUSL <br /> T 12-1cm01 Ski✓ i <br /> Y 39- <br /> K 39- <br /> 39- <br /> 39- - <br /> LIST ADOITIONIL TIHK INFORHITION AS NEEDED ON SEPARIT& FORK <br /> uuuYDllYUuut1YYYYuuuWllYilluuWUWIWRuuuuUWIIRIYWuIWIW�CII YL1WlWVW(VI;iIIYUWIIWYI1Ji11Yl"itll�;IiIWW!Ylllrllu9UWIWr�YWL'9L'YI!JIYtiW?WNUIl�9Vy��YI'L'VUYJLiJ'�GuuUI�N'.RIIWIWou4lllCWUUW1WIuuuWtlWUYGWW�auWYWW�I�IULuuUEIiIWWYC; , <br /> P __ APPROVED _APPROVED WITH CONDITIONS DISAPPROVED <br /> L /) (SEE ITTICIIKENT WITH CONDITIONS)— <br /> I PLAN REVIEWERS NIKE L', cam_-- <br /> N <br /> WNYYOUWUImIYiYYYlY1WiYWId1lYll40mNIIWIYIYYIDWWfWl1��!�Yun umanuwiiuu u,n �w u ,� �uuu� Hutu wwx iYiYWYWIGYiIYYYWI6RUYW1rdY1W�YlYYWWYIWBYlWn1Y01Y1lWWWYLItlYi <br /> APPLICANT MUST PERFORM ILL YORK IN ACCORDINCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LIPS, AND RULES IND REGULATIONS <br /> OF THE SIN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNITURR CERTIFIES THE FOLLOYING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IM SUCH MINNER IS TO BECOM <br /> SUBJECT TO YORKER'S COMPENSITION LAYS OF CILIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOVING: 11 CERTIFY THAT IN THE PERFORMANCE OF THE YORK FOR WHICH 11115 PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUOJEC <br /> TO YORKER'S COKPENSITION LAWS OF CALIFORYII. <br /> CALL FO INSPEC IONS AT LEAST 40 IIOURS IN ADVANC <br /> 7 <br /> SIGNED DATE 2 <br /> OFFIC ONL - BII 23 0 111 <br /> SSSSSSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSISSSS <br /> Sl�� !-I COMP I LOC CODE IDIST r CODEI IM B IM VD -CjCvH I`-?VD BY I- O�t�&C�D- I PERMIT 1 <br /> Gds 4f 1 �-t_ I <br />