Laserfiche WebLink
r tt.tt tt t I'It ti:Its III ft It:It It It:It:It:tt It It:It:tt ft It:tt tt tv—, I:It It tt <br /> APPLICATION FOR PERMIT k: SIN JOIQUIN LOCAL HEALTH DISTRICTt: <br /> t: UNDERGROUND TANK t: 1601 E HAIRLTON AVE., STOCKTON Cit <br /> t: CLOSURE OR IBINDONMENT t: Telephone (201) 168-3120 t <br /> Ill: t kill:tt:R11:It:It:tit:R:ft It:tt kill:It'R:It R R:It:tt'tt'It:It:IV It It:It:It:It <br /> APPLICATION POR PERMANENTITEMPORIRY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND Hlt►RDOUS SUBSTANCES SfORIGE FICILITY <br /> THIS PERMIT RKPIRES 90 DIPS FROM THE APPROVAL DATE. DO NOT WRITE IN III SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> — REMOVAL --_ TEMPORARY CLOSURE _& ABANDONMENT IN PLICB <br /> EPA SITE 1 t' C G c c I L."t X0 5 — PROJECT CONT/CT & TELEPHONE I -- <br /> P FACILITY tlINEV—.h�� P4)rvi 5 �f OC.e-T' PHONE 1 931-6691 - C — 0 <br /> A — _ J a I�j< LSO __ ctnD <br /> C ADDRESS6-7 3 E. — <br /> L CROSS STREIT <br /> T OWNER/OPERATOR PHONE I <br /> Y trio bozZa no <br /> C CONTRACTOR NINE - — PHONE i - --- - - <br /> r CONTRACTOR ADDRESS CI LIC t <br /> — -- --- ��-7,2 5 3-- cLdss jfiG <br /> R INSURER �} l� `` WORK.COMP.1 <br /> C PIRG DISTRICT --FP <br /> RRMif I/INSPTA— — - -- <br /> 0 LABORATORY NIMB N IPHONE 1 NIA <br /> SAMPLING FIRN= 141A [NG METHOD <br /> TANK ID I TANK SIZE CHEMICALS STORED CURRENTLI CHEMICALS STORED PRBVIOUSL <br /> T <br /> 1 19-__11,30_o l <br /> K 31- <br /> --- <br /> LIST ADDITIONAL TANK I9101MITION 1S NEEDED Or SEPARATE FOBN <br /> IPPROVED IPPROYBD WITH CONDITIONS DISAPPROVED <br /> L (SEE ATTACHMENT WITH CONDITIONS) <br /> 1 PLAN REVIEWERS NAME <br /> P <br /> APPLICANT MUST PERFORM ILL WORK Ir ACCORDANCE WITH SAN JOIQUIN COUNTY ORDINANCES, STITE L►WS, AND RULES IND RECULITIONS <br /> OF THE SIN JOAQUIN LOCAL REILTH DISTRICT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY ?HIT <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 10 WORKER'S COMPBNS►TION LAWS OF CILIFORMIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, l SHILL EMPLOY PERSONS SUBJEC <br /> 10 YORKER'S COMPENSITION LIWS OF CALIFORWII. <br /> CALr/i <br /> R INSP - CTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED�C } <br /> OFFIC <br /> B USB 0 Y--BH 23 016 12/11 <br /> SSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SYB;3U COMP I LOC CODE IDIST CODEI AMOUYf„DUR I AMOUNT HCVD I CK^I/CISH I RCPD BY TR RCYD I PERMIT <br />