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' k a tvamk$klt -;Ktltl:ktAli <br /> kk/ tt tttt l� . �! .S7 <br /> t: APPLICATION .MIT N MAI LOCRE H1H 1C1t, s <br /> t: UNDERGROUND TANK G 1601 E HAZELTON AVE., STOCKTON CA t: CAO <br /> t: CLOSURE OR ABANDONMENT t: Telephone (209) 468-3420 t <br /> :'.-wp- rn:n:n:�r.�.:Ir.n:.x n:n:n:::::: <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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL ----- TEMPORARY CLOSURE --__ ABANDONMENT IN PLACE <br /> EPA SITE i PROJECT CONTACT f TELEPHONE 1 �. <br /> F FACILITY NAME / _ 2v 6 <br /> A ( PHONE 1 ` 6. <br /> ADDRESS ��r ` .d <br /> L CROSS STREET v( ,� <br /> I — <br /> T OWNER/OPERATOR PHONE 1 —i <br /> CONTRACTOR NAME /1 /O r �L/ r• / L PHONE 1 f, <br /> 3 // rT1 C a�` onf sc-a ivYl <br /> f T <br /> CONTRACTOR ADDRESS cy - �•�4 /,f CA LIC 1 5, 7 v CLASS <br /> ' � I C r'C Oo•1 5 ---�— <br /> I INSURER WORK.COMP.1 D ry <br /> FIkE DISTRICT C PERMIT I/INSPTR <br /> 1 LABORATORY NAME � t �� PHONE i L <br /> �`- p <br /> SAMPLING FIRM* _ SAMPLING METHODT/ <br /> wwwwuuuumPr T/ <br /> TANK ID I TANK SIZE CHEMICALS STOPED CURRENTLY CHEMICALS STORED PREVIOUSL <br /> 39 - -- - a <br /> 39 <br /> --------------------------- <br /> 39 <br /> 39 <br /> --------------------------- <br /> 39 <br /> --- ------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> ---- APPROVED __ APPROVED WITH CONDITIONS ---_ DISAPPROVED <br /> 12(SEE ATTACHME T WITH CONDITIONS) <br /> PLAN REVIEWERS NAME7 -- <br /> .......... - - -------------- / <br /> -----------------------DATE >' 8 <br /> 'PLICANI MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING,: •1 CERTIFY THAT <br /> 4 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br /> 18JECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> ILLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> I WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> NEO -- -- - -- --- - -----------------------------------------------DATE_ <br /> f-10E Uf[ OAIY--EB I3 016 -12/88 - -' - -- - - - <br /> 41$Hssf0s1000100s01ssffsffsffsfffsffffffffffiffffffftfsffffffffsfffffffffffsffssffffff000ffsfffffssffffffff <br /> EPS t I COMP 1 LOC CODE DIST CODES AMOUNT DUE AMOUNT RCVD CKIICASH —RCVD BY� I—DATE RCVD-_�P�IT t I <br />