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ttrtrtrttt�tat��:teeattt�txta'rtt� at�t�rtl;tr;tttzr; tett ���AZ_ G� ���'�' <br /> e 1PPLICITIO1 FOR PERMIT w SIN JOAQUIN LOCAL HEALTH DIs[RICTw <br /> t UNDERGROUND TANK t: 1601 E RIZELTON ITS., StOCK101 Cit: <br /> r CLOSURE OR ABANDOWMEIT g Telephone (2091 118-3128 t <br /> t it:trtrtrtill:ti:trtrtit:trtrtrti:trti:trti:trRrtrtrta tru trtrtrtratrtr <br /> APPLICATION FOR PERMINEIT/TRMPORIRT CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND 11111DOUS SUBSTANCES STORAGE FICILITY <br /> THIS PERMIT EIPIRRS 90 DAYS FROM THE APPROVIL DITE. DO NOT I1176 II 111 SUD11 AREAS. INDICATE PERMIT TYPE IBLOW: <br /> _ 18MOVAL TEMPORARY CLOSURE _ IBIIDONMEBT IN PLICI <br /> T <br /> BPI SITE I C a �9 110JBCT CONTACT A TELEPIDII 1,,G �rAAJ ib i <br /> P FACILITY NAME S c l C C PHONE 18 3 5 7Y <br /> C ADDRESS ! C <br /> I <br /> L CROSS STREET 1 3 <br /> I <br /> T OWNER/OPERITOR Ge i'6 ?e-rA-g 15 k' =Igo-79'3 S 3 <br /> 1 <br /> C CDNIR1CT08 NINE Gep r PEONS I A C o 83 S 3 ,5 <br /> 0 7, a <br /> N COITIICTOR ADDIBSS 6 D u r� a ru Far eA Cl LIC I CLlSS <br /> T <br /> I "SUSIE 144A,1oVer' /'--'S CD IORI.COMP.I 31915 <br /> 1 <br /> C FIRE DISTRICT Tr A L PERMIT I/IBSPTR _ <br /> 1 <br /> 0 LABORATORY MIME FG L. 4AP41l TJca L PROLE I X09 4c <br /> R <br /> SAMPLING FIRM' G L /� N 9 L,rtca L SIMP6ING METIOD S6'sL <br /> ?III ID I TAKE SIZE CHEMICILS STORED CURREITLI CHEMICALS STORED P187IOUSL <br /> T <br /> 1 39 e c v <br /> I 39- 5-0— Y <br /> K 39- <br /> 39- <br /> 39- <br /> LIST ADDITIONAL TIME INFORMATION 18 IHEDBD 01 SEP/RITE PORN <br /> p IPP90VED _ PPROFID WITH CONDITION _ DISAPPROYED <br /> L Q (SBE Atf IMENT WITH CONDITIOIS) 2 <br /> 1 PLIN REVIEWERS NINE DATE <br /> 1 <br /> APPLICANT MUST PERFORM ILL WORK 11 ACCORDANCE WITH SIN JOAOUIN COUNTY ORDIIINCES, STATE LAWS, AND RULES TND REGULATIONS <br /> OF THE SAN JOAOUIN LOCAL IEILIH DISTRICT. OWNER OR LICENSED AGENT'S SIGNITURE CEITIFIES THE FOLLOVIIG: 11 CERTIFY THAT <br /> if THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHILL NOT EMPLOI ANY PERSON IN SUCH MINNIE AS TO BECOM <br /> SUBJECT TO WORIER'S COMPENSATION LAWS OF CALIFORNIA.' COMTRICTOVS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY THAT IN THE PERFORMANCE OF TI16 WORE FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LITS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED M qd tii� DATE I - <br /> OFFICE USYONLY 811 23 016 12/11 <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSs'SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS I I COMP I LOC CODE DIST CODE ►MOUNT DU8 IMOUNT RCVD I CK1/CISR I RCVD BY I DITE RCVD I PERMIT I <br />