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f.R;t1.t1-c1= t�-!1:kv.Rvt1.t1.t1.tial.r1-t;.tyt;.R:%TtT.Ix.r�rr{r�r -..t <br /> r IPPLICIt fu r' 1 PERMIT SIN JOAQUIN LOCAL HEALTH v v to r: <br /> r: UIDBRGR6— TANK c: 1b01 B H116LtON 118.1 STOCKT. 1 f <br /> c CLOSURE OR 1SINDOMMINt 1 Telephone (209) 161-3629' t.. <br /> at;c1 t;c1:t1-t1.t1.Fr-R.RTVt.r1,t1.t1-t1.t1.t1.t1.r1.t1.t;.R,V.M.V-t1-t1-t:.t1-t;.t1.t1- <br /> IPPLICITION FOR PIRMAKBNT/TBMPORIRY CLOSUII OR ABANDONMENT IN PLICB OF UNDERGROUND 81111DOUS SUBSTANCES STORIGE FACILITY <br /> ?NIS PERMIT BIPIRBS 90 DIPS FROM THE IPPROVIL DATE. DO NOT 111T6 IN 111 SNID11 AREAS. INDICATE PERMIT TYPE IBLOK: <br /> ' RINOVAL TEMPORARY CLOSURE ABANDONMENT IN PLICI <br /> BPA SIt6 I PROJECT COITICT i TELEPHONE 1 ��� I I rAw� �f 7a7 <br /> F FICILITY MINE �►4 W l PHOKe 1 aV g_���_ S-b ! <br /> I <br /> C IDORBSS 10 0 <br /> 1 <br /> L CROSS StI111 <br /> I <br /> I OVNER/OPERATOR PHONE <br /> 1 Co Let v 4�b <br /> C CONTRACTOR RINI 6R LS Pools la D I — b 7 q7 ;) -7 <br /> 0 - CA LIC I q-7�'33S CLASS . <br /> N COKTRIC?OR ADDRESS 3 _3 p-u• j S Zl4 <br /> I _ 0 <br /> R INSURBR �• VORK.COMP.! �� <br /> 1 <br /> C FIRE DISTRICT PBRNIT I/INSPTR <br /> 0 LABORIfORY NIMB �_� `r PHONE ! 0c� ���; ? D -z/ <br /> R <br /> SIMPLIKG FIRM' , ` � e�� SIMPLING METHOD <br /> • Imo'-�'+1I �8ElG'�6•�+::� �r,�iRIE ----- <br /> TANK to i ?III SITE CHEMICALS STORED CURRINTLI CHEMICILS STORED PRIVIOUSL <br /> t innijuLcricL _e 1 5 � <br /> 1 39-_ C,�_ U <br /> 1 39-��t <br /> I 39- <br /> 39- <br /> 39- — <br /> LIST IDDITIONIL ?INK INFORNITION IS NEEDED ON SEPARII6 FORK <br /> wa: °.urlC1G ��J'�W1Q6lPiIWU�Ifflkll�IClr141f!�U6'UGUILWIpI@9191MIIilp1"�ykltllJillA'�I VJm616p01 , p'"u1I111B4"�!�'1Rl'�I:�it' : <br /> P IPPROVED _ IPPROVBD VITH CONDITIONS _ DISAPPROVED <br /> L (SEB ATTACHMENT VITH CONDITIONS)r <br /> 1 PLIK RBVICVIRS 11116 , �� __DATE //�-9 - <br /> K <br /> IPPLICANT MUST PERFORM ALL YORK IM ICCORDINCE VITH SIN JOIQUIN COUNTY ORDININCES, STITB LIVS, AND RULES IND REGULITIONS <br /> OF ?HB 311 JOAQUIN LOCAL RBALTN DISTRICT. DOER OR LICRIS90 AGENT'S SIGNITURB CERTIFIES THE FOLLOVING: 'I CERTIFY THAT <br /> 19 ?NB PERFORMANCE OF THE 1011 FOR VRICN THIS PERMIT IS ISSUED, I SHALL 101 EMPLOY INY PERSON IN SUCH NIKKEI IS TO BECOM <br /> SUBJECT t0 YORKER'S COMPBISITION LAV$ of CILIFORNII.' CONTRICTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TRS <br /> FOLLOVIIG: 'I CERtIPY THII 11 ?N6 PERFORMIKCB OF tilt YORK FOR VNICH THIS PERMIT IS ISSUED, I SHILL EMPLOI PERSONS SUBJBC <br /> t0 VORKBR'S COMPENSATION LIVS OF CALIFORKII. <br /> CALL C ONS LEAST 40 HOURS IN ADVANCE <br /> SICKED ` M___ DIt6 G <br /> OFFICIt USB ONL -BI 016 R/11 <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS;SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSlSSSS <br /> SVIEPS 1 COMP I LOC CODE DIST CODE IMOUNT DUB AMOUNT R CK1/CISR RCVD BY 0111 RCVD PERMIT 1 <br />