Laserfiche WebLink
v <br /> I: t I:t I!ffkl:ti:RI:R111-1:R:ft L V R:t I:ft R:fftl:R:t1:ff ff ft ft R:ft R't V <br /> APPLICATION FOR PERM[-, k: SAN JOIQUI 8 LOCAL HEALTH DISti ICT k: V <br /> JIDERGROUWD TANK t: 1601 9 HAZELTOM AVE., S?OCK?01 CAt: <br /> CLOSURE OR ABANDONMENT t: Telephone (209) 468-300 1: <br /> ti: <br /> I-11AY L 91 <br /> APPLICATION FOR PERMANENT/TEMPORIRT CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS vA SUBSTANCES STORAGE FA�I_LITY l�i <br /> THIS PERMIT EIPIRFS 10 DAYS FROM THE APPROVAL DITE. DO NOT 11178 IN III SHADED AREAS. INDICA 00'� " <br /> 'A <br /> , ETITIN <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE I PROJECT CONTACT i TELEPHONE I�14-r— M T <br /> 640-ICD-3 <br /> ? FACILITY NAME Slir-LL S e"Lj✓ STA Tj 'I- PHONE 1 <br /> C ADDRESS <br /> I <br /> L CROSS STRUT (6i-T� kX,6,-T5t> i d C <br /> T OWNER/OPERATOR PHONE I <br /> _74- <br /> C CONTRICTOR MINEPHONE 1 (41s)183- T�­Oc, <br /> 0 -.-f <br /> I CONTRACTOR ADDRESS IC)92CA LIC I CUSS <br /> 7 - _ /A �VL:� <br /> R INSURER WORK.COMP.1 <br /> C FIRE DISTRICT COLJO.Ty C>r-- Gl--14J J PERMIT I/INSPTR <br /> 0 LABORATORY WINE PHONE 1 <br /> R <br /> SAMPLING FIRKt MPLING METHOD (494,�O �c—:—T W)D <br /> TANK ID I TIKK SIZE CHEMICILS STORED CURRENTLY CHEMICALS STORED PREVIOUSL) <br /> >CX� &t^L <br /> 1 39- ASO i,,J k5 <br /> c- <br /> 39_______ <br /> 39- E��c co <br /> 39- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED 09 SEPARATE FORK <br /> P APPROVED _APPROVED WITH CONDITIONS --- DISAPPROVED <br /> L (SEE ATTACHMENT WITH CONDITIOVS) <br /> A PLAN REVIEWERS MAKE <br /> APPLICANT MUST PERFORM ALL YORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES IND REGULITIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINC: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR YHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOSR <br /> SUBJECT TO WORKER'S COMPENSATION LOS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SICHATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR iHICH THIS PERMIT 15 ISSUED, I SHALL EMPLOY PERSONS SUBJECI <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA, <br /> CALL FOR INSPECTIONS AT LEAST 48 [TOURS 114 ADVANCE <br /> SIGHED c <br /> OFFICE'US�OHLY­ 1123 046(-17181 <br /> SM$ssssssssss'sSj <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUEJ AMOUNT RCiD CK1/CASH RCVD EY DATE RCVD PERMIT I <br />