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k:kt;ti:kyk�. t��k��kfi�tk�k;�kt�k��k�t3�k2�t'��k��k��k��kx�t�� t <br /> k��k� ��t��i �k�kx�k�� <br /> LIC. - <br /> _ s - APPN FOR PERMIT SAM JOAQUIN LOCAL HEILTSTRICTk: <br /> k: UNDERGROUND TANK k: 1601 8 HAZELTON 198., STOCKTON CAk: <br /> CLOSURE OR 18ANDOEM991 k: Telephone (209) 168-3420 k: <br /> APPLICATION FOR PERHANE9TITEMPORIRY-CLOSU21 OR ABANDONMENT IN PLACE OF UNDERGROUND HAZIRDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EKPIRES 90 DAYS FROM THE APPROVAL D1T8, DO NOT WRITE IH III SHADBD AREAS. INDICATE 'PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE ABANDONMENT IM PLACE <br /> _ EPA SITE 1 G/awG'Q� �q rj �{q�j PROJECT CONTACT S TELEPHONE I JEFF T Lo g_ <br /> _C9 I61 646-40V3 <br /> F FACILITY NAME SHELL PHONE t <br /> I �2 ) 477• em4 651TE) <br /> c ADDRESS �! 5 N . FVRS H I r-J AVE SToGlC`TorJ q 5207 <br /> 6 CROSS STREET (Z01j E MAR 1E LA Q E <br /> T OYNERIOP.ERATOR PHONE I <br /> .T C RE6CRY 5. G.IRROLL (2-09) -4727 1:110-7 1,07 (NOME) <br /> c cON7RlciaR MIME SEE rkT—TACH E p Lt ST PHONE I ---- T <br /> o ' <br /> N CONTRACTOR ADDRESS Lr CA LIC I CLASS <br /> R INSURER YORL COMP.I <br /> C FIRE DISTRICT FIRE- C) PERMIT I/[NSPTR <br /> T <br /> 0 LABORATORY NAME 4 NONIE LA&RATbR IES PHONE C2o9) gf33. 13gq <br /> SAMPLING FIRMt C A-Q0wiF_ IAP aRAToRI ES SAMPLING METI OD GRag "M ETHO D <br /> m�1�nmDmo>o�Ra�laDR�B1�uRmalDml�rmm <br /> TANK ID I TASK SIZE CHEMICILS STORED CURRENTLY' CHEMICALS STORED PRBVIOUSL <br /> T <br /> A 39-_jw�0) <br /> N 39-��85 -16`_�_ � /� Nva • <br /> X <br /> 39- <br /> 39- <br /> 9 39- CM) nALLciQ5 E6 U LAP Uki LEAM��•M� <br /> LIST ADDI7[ONIL TANK INFORHATION AS NEEDED 09 SEPARITE FORK , <br /> RRDfRiIIYI�I�IfllRlll�iR�llpl ➢WGAI DtlIHIdDYID@.��fDP4!?p1 liU l?mIiRNDaiI DDIDYI;?uliC511ChEpIBIDIIYI{6lYSCDI!7191 I(ISflNCSD7 �KgDpNPPDII2992H1mDI120 MIG01011.g1DIWfuIU'm1lI!!1mlw <br /> P APPROVED PPROVEO VITHICONDIT[ONS _ DISAPPROVED <br /> L IS ATTACHMENT WITH. CONDITIOVS) ' <br /> A P,LAM. RREEWERS NAME � DATE B g� <br /> DV{Y�mmmYi�fm1GIEI�fmfWltq 911CI�Id1UNYmlIIDIU&I!➢ HN11mDWmdIB�IRGIDI�mmlmDlIRIlf�6'�DWmmtlimHBUli4lYlm�mmllBDmli�Ilmdm�fllfJllmRlmmQtlmiml '! <br /> IPPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDININCES, STATE 1,111S, AND RULES IND REGULITIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, 15N1LL NOT EMPLOY ANY-PERSON IN SUCH MANNER AS 70 BECON <br /> SUBJECT TO YORKER'S COMPENSATION LIPS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF T118 YORK FOR VNICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO YORKER'S COMPENSATION LAYS OF CALIFORNIA. <br /> CPLL FOR INSPECTIONS AT LEAST 40 FIOURS IN ADVANCE <br /> SIGHED_ <br /> OFFICE U$E ONLY--E1[ 11 DIS I1/11 ---__�---DATE <br /> SWEEPS ( I nCOMP/ € I LOC CODE [CODE AMOUNT OUE AMOUNT RCVD CK1/CASR RCYD 81 f 0119 RCVD I PERMIT 1 <br /> Val___-_•�_-��I __.�. -�----� �. 4 <br />