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F . A <br /> f lZ:ti Ci'k' 'takrti:til tilillan.kA.N,Ci till4vii CYokkut 1vt%:0 <br /> v APPLICR FOR PERMIT i SAN JOAQUIN LOCAL HEALTH...rfRICt Y <br /> r UNDERBROUND TANK r 16DI E HAIELTON AVE., STOCKTON CA a <br /> e CLOSURE OR ABANDONMENT !; telephone (209) 468-3420 ,�? � � a <br /> t <br /> !Blit C '! lrp:trlRi t i!>A rlrlYty r.'>'tfilxlC :lrlrli �lil:li <br /> APPLICATION FOR PERMANENTJTEMRORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND WAIARDOUS SUBSTANCES STORAGE FACILITY <br /> THIC PERMIT CIPIRCC 90 DAYC FROM THE APPROVAL DATE. DO NOT WRITE IN ANY CHADED AREAC, INDICATE PERMIT TYPE IELOWI <br /> X REMOVAL ..... TEMPORARY CLOSURE _.__ ABANDONMENT IN PLACE <br /> EPA SITE #(2 PROJECT CONTACT 4 TELEPHONE <br /> 5 — — <br /> F FACILITY NAME <br /> A PHpNE 1 _ <br /> a <br /> rp <br /> C ADDRESS <br /> Li <br /> L CROSS STREET <br /> I Y� � �✓7 i Lv �. � -- - <br /> T OWNER/OPERATOR <br /> Y PHONE 1 <br /> C CONTRACTOR NAME PHONE t <br /> Or - �a- ss - s <br /> N CONTRACTOR ADDRESS / ��,�.,.��> CA LIC i <br /> T �r /A � e�d�o ( �„�Q�Py� <I 5 7c LASS PF <br /> R IMSIIRFR �1 O1 YORK.COMP.1 6> <br /> C FIRE DISTRICT PERMIT I/IHSPTR <br /> T —77 <br /> 0 LABORATORY NAME L / <br /> R <br /> SAMPLING <br /> 1 (16d—�2 <br /> ONO FIRMt SAMPLING METHOD <br /> TANK 10 1 TANK SITE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> r <br /> A 39-... J q 7:: <br /> N 39- <br /> -------- - <br /> K 39- <br /> 39- <br /> ..�------^--------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P ' <br /> APPROVED PPROVED WITH CONDITIONS DISAPPROVED <br /> t E ATTACHMEN WITH CONDITIONS) / 7 <br /> A PLAN REVIEWERS NAME ,�,y�. 2— .0 <br /> N _ . . ._... - - DATE... ........ C ....... <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOABUIN�COvMTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINGi '1 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 BECOM <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOW1NGi 'l 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 /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED <br /> OFFitF USE ONLY-`•FN 13 016 11IS8 ........ .......... ....._.. <br /> ”""_- '"'----_-DATE........ <br /> -- ................ <br /> I ssssstssstsssstsssssssssssssssssstsssssssssssssssssssssssssssssstssststsssssssssssssssssssssssstsssttssssssststsssttsttts <br /> SWEEPS t I COMP t LOC CODE 01ST CODEJ AMOUNT DUE I AMOUNT RCVD I CK1/CASH 1. RCVD BY DATE'RCVD_ PERMIT 1 <br /> I <br /> I <br />