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tf„nNK»tKNNKf(�RKflRKf�f(NNK�N»t�KK�»fq KK»(.tt.«�.H.ffn.K.n�.K.ff«.«.�,�.»tff�»t�.f(. f(»(�ff»iNfl�`tN»<»tp <br />p APPLICAT N FOR PERMIT p SAN JOAQUIN LOCAL HEALTH RIOT <br />p <br />UN; <br />UND TANK p 1601 E HAZELTON AVE., STN CA <br />a <br />' CLOSURE h ABANDONMENT Telephone (209) X468-10,4:1' a <br />tl»�tf:f ��ffffff�Kfi#f: ffff"ffff »'ff„ fiffk�;fff£: � #f7lf »<R'ff!ffffiffff Aff»tlff<ff�ff:f»�ff:f �fff ff�flFifff:f:: iiff fluff <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />ZPEMOVAL TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br />EPA SITE I C'sc coo CONTACT f TELEPHONE f <br />F FACILITY NAME -,-Fe <br />�/ f 'I in PHONE # 0 � �� _ o i, <br />A <br />IADDRESS32 2-E Real(L CROSS STREET <br />t <br />T OWNE O:pllTOR PHONE B <br />Y 7, Ore <br />C CONTRACTOR NAME <br />0 <br />N CONTRACTOR ADDRESS <br />T <br />R INSURER <br />A <br />C FIRE DISTRICT <br />T _ <br />0 LABORATORY NAME, t <br />SAMPLING FIRM* <br />TANK ID I <br />T <br />(I 39- L -7:::--C - -- <br />-- ------ <br />K <br />39 <br />.. <br />,9- <br />-------------------------- <br />PHONE D <br />CA LIG i CLASS <br />WORK.COMP.f <br />[PERMIT i/INSPTR ---_ <br />— PHONE 14CC <br />l <br />SAMPLING METHOD <br />TANK SIZE ICHEIMICALS STORED CURRENTLY CHEMICALS STOPED PREVIOUSL <br />LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br />P ____ APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br />L (SEE ATTACHMENT WITH CONDITIONS) <br />A PLAN REVIEWERS NAME <br />--------- - L-=---- - - (L-----------------------DATE-------� - - --- ------ <br />N <br />�----- <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 CERTIFY THAT <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 TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' 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, I SHALL EMPLOY PERSONS SUBJEC <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br />CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br />SIGNED DATE <br />OfFICE USE ONLY <br />fififfifffffffiSfffffff3ffSfifffffffffiSfiffSfffiffffiffSSSffSffiffffiSfffSSSSff#ifSffSffiSSSifffffSfffSSffffffffffffiSff! <br />SWEEPS I COMP I 'LOC CODE 'DIST CODE AMOUNT DUE AMOUNT RCVD ' CKS/CASH RCVD BY DATE RCVD ' PERMIT 1 <br />i <br />