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$'APPLICATION F PER <br />A UNDERGRO NI,';�nEz f�OnsE <br />{ 'N CLOSURE Og :A DUN*Lic. <br />co �n*177928 Service Stations Commercial <br />APPLICATION Fog PERMAIIENMEMPORARy CLOSURE OR ADjj 2180 ENTERPRISE OR4A 95SOULEVA6 <br />WEST SACRAMENTO. CALIFOR A 9569 <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DAT) G FACILITY <br />BELOW: <br />�✓ ,,, „_ REMOVAL <br />EPA SITEDENNIS PARIKKA (916) 372-1985 / FAX (916) 372-0911 _p copy <br />S �, � .� <br />CFTC ` o� � <br />A FACILITY NAME <br />PHONE 1 <br />e• l <br />C ADDRESS <br />L CROSS STREET <br />I <br />T OWNE OPE TOR <br />Y /+ PHONE 1 <br />C CONTRACTOR NAME C <br />0 PHONE M <br />N CONTRACTOR ADDRESS <(D -37a -O 2 u <br />T CA LIC 1_ CLASS C 6 / <br />k INSURER <br />A C 16A --W NORK. COMP M , 3 - ` �� <br />C FIRE o STRICT -� -3 _ <br />T 1►Z14C ;�`�PERMIT 1/INSPTP. <br />0 LABORATORY NAME �' d�A. <br />R PHONE N C�1� <br />SAMPLING FIRM"°`�-3 <br />S �C} SAMPLING METHOD <br />TANK 10 i�` tANK512E <br />T CHEMICALS STORED CURRENTLY CHEMICALS STOPED PREVIOUSLY <br />r9. & ....... <br />�3- <br />-rr-r---Yi1YYJ...i.aJ:ILrrY <br />LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br />P APPROVED -__ PPRDVED Hiles CONb(TIONS ____ DISAPPROVED <br />A PLAN REVIEWERS NAME - (SEE ATTACHMENT WITH CONDITIONS) <br />N --------- •--------- ----- DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br />OF THE SAN JOAQUIN LOCAL HEALTH DISTRICt. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFYTHATIN THE PERFORMANCE Of THE Wogk FOR WHICH THIS PERMIT 15 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER. AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CAI.IFORNIA:' CONTRACTOP.IS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: 'i CERTIFY THAT IN THE PERFORAANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIAN SUBJECT <br />CALL FOR INSP I AT LEAST 48 HOURS IN ADVANCE <br />OFftCE Nll--....z•-,..__.---------------------------------------- -0ATE__ � d •� <br />i'tititiiifitiitttftittitttttttittittitttttittl�tititiiftitiitiittiiiiiftttsiitiitiitttttifititittttifiififttitifitttitti <br />WEEPS 1 ' COMP i 'LOC CODE 'DIST CODE AMOUNT DUE � AMOUNT 9CVD CKI/CASH RCVD BY ' DATE RCVD I PERMIT 1 <br />