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rt t; t;:cv.ti);t:-c�.e;-rptv.tvtve;.t;.t3.t;.Ix.n:r�aat� -'vtvt%*tv.IPPLIJOI FOR PERMIT �: SAN JOAQUIN LOCAL H21LTN"DISTRICTt: <br /> t: UIDERGROUND TANK t: 1601 E WELTON AVB., STOCKTON Clt: <br /> t: CLOSURE OR IBINDONNEN? t: Telephone (209) 468-3420 t: <br /> t.ti:R:R:t::ti:R:ti:tfi-tx.txt.R:t;*W.t3:tx.t;:R:tt'tz.t:.t;-t3:tv-R,t;.,R:t:r.R:R:R:tj:t3: <br /> IPPLICATION FOR PERMANENT/TEMPORIRY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZIRDOUS SUBSTINCES STORAGE FICILITY <br /> THIS PERMIT EXPIRES 90 DIPS FROM THE APPROVAL DITE. DO NOT IRATE IN III SHADED AREAS. INDICATE PERMIT TYPE IELOY: <br /> X REMOVAL TEMPORARY CLOSURE _ ABANDONMENT IN PLACE <br /> EPA SITE t PROJECT CONTICT i TELEPHONE I J L 2F Y Gc b(-N <br /> CAS ��o i355(o 2a�11 A5 - 3. <br /> F FICILITY NAME lvAL M-1EC k L-inlIFI c--b SC_N-boL <br /> I hie % Lt c- C-LsvY1 0 LLk I <br /> P101E t (LcA) t5a5 - 3aoD <br /> C ADDRESS arc)I C L nUISL A\1L LAI N LoP LA 9533p <br /> I <br /> L CROSS s?REKt A`92D�.` VV ft <br /> I <br /> T OVNER/OPBRITOR PHONE t <br /> Y mAkIECA -D(S�QtLl (Z'dM LD,S - 3J-00 <br /> C COITRICTOR KINE 'SEL SI O�I`1 �1 ni u S i eA ES PHONE I(�.D�I� �l(Z -Ci 611 I <br /> 0 <br /> K COKTRICTOR ADDRESS(oyl CA LIC I [cLAss A E <br /> T <br /> R INSURERDR I D CASU �.t�I VORK.COMP.1 W.L-W. (gJ� yob—' �6 - ul <br /> A _ <br /> C FIRE DISTRICT C_tl,l - at, -MHN l CcA PERMIT I/INSPTR <br /> T <br /> 0 LABORATORY NAMEL�L,F� t u�f UILL LASS 1101E ICZol) nal- 4DSO <br /> R <br /> SIMPLING FIRM C Auk--b i A L,)A AT e-L LAS I SIMPLING METHOD <br /> TIII ID I TANK SIZE CHEMICILS STORED CURRENTLY CHEMICALS STORED PREVIOUSL <br /> T �, / I DD D C A LLd nI REG. �A�O C-NK xi Al A <br /> 1 39-_�''t�______ <br /> Y 39- <br /> [ <br /> 39- <br /> LIST IDDITIONAL ?INK INFORHITION IS NEEDED ON SEPARITE FORK <br /> gp Bll1lgi '�' 9Lirll� 1=2 19= <br /> P APPROVED _IPPROVED VITH CONDIT109S _ DISAPPROVED <br /> L (SEE 0TICNME111 VITH CONDITIONS) <br /> 1 PLIN REVIEVRRS 1AME G2% ��� _DITE /a3��Z� <br /> a <br /> IPPLICINT MUST PERFORM ILL YORK 11 ACCORDINCE VITH SIN JOIQUIN COUNTY OROININCES, ST1TE LIVS, IND RULES IND REGULI?IONS <br /> OF THE SIN JOAQUIN LOCAL HEALTH DISTRICT. DINER OR LICENSED AGENT'S SIGNITURS CERTIFIES THE FOLLOVING: 11 CERTIFY ?HIT <br /> IN THE PERFORMANCE OF THE YORK FOR VHICH THIS PERMIT IS ISSUED, I SHILL NOT EMPLOY ANY PERSON IN SUCH MIKKER IS TO BECOM <br /> SUBJECT TO YORKER'S COMPENSATION LIVS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOVING: 'I CERTIFY THAT 11 THE PERFORMINCE OF TIIE VOR[ FOR VNICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO VORKER'S COMPENSATION LIVS OF CILIFORYII. <br /> CALL FOR INSPECTIONS AT LEAST 40 FIOURS IN ADVANCE <br /> SIGNED _ DATE_-__/_ /Q __ 7 <br /> OFFICE USE ONLY--BH 23 046 121itl <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> STEEPS 11COMP I - LOC CODE I DIST CODE' INOUKT DUB I AMOUNT RCVD CKI/CISH RCVD BY I DITE RCVD I PERMIT I <br />