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APPLICATION FOR PERMIT t:' -'AA JOAQUIN LO d- HEALTH DISTRICT, <br />t: UNDcRGkOU; K k, 1601 E HAZELTON AVE., STOCKT.ON X", I <br />CLOSUIRE OR ,ONMENT U: Telephone (09) 4i9 -.','I20 <br />!:h}:}}:Y}:h}:}}:}:Y:h}'YY;}Y;}:Y}:}:}:Y}:}}:h}:}}:KP: }}:Y}:Y}:}};KP: PY:}J.:Y}:}}:KP: Y}:Y}:}}:}.}: h}:i T: <br />VPLICAIION FOR PERMANENT/TEMPORARY CLOSURE 09. ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY' <br />TIS PERMIT cfPIRES 90 PAYS FROM THE APPRDVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW; I <br />EMO`JAL TEMPORhr',Y CLOSURE ABANDONMENT IN PLACE <br />E(cA SITE I I PROJCCT CONTACT L TELEPHONE I <br />1 - <br />Fl. FACILITY NAME 1) <br />C ADDRESS <br />I f�=1L_lt_.LJ �—r_.�._�_..1._,��I.>.�..t!.J._ _ h'l.._ ._ . �,!.��__—l-.Y::.i.__.1�__:•l!�..._.��_�.--��----------------• <br />L CROSS STREET <br />M ' <br />.._.._........... .... _.... ___...... _ 1! <br />T OhNER/OPERATOR, A., PHONE it <br />�_. <br />J- <br />C CONTRACTOR, NAME <br />!i CONTRACTOR ADDRESS <br />T_T� rn E��F S : ......... .j''_ _� t <br />F INSURER <br />A <br />C. FIRE DISTRICT <br />T <br />0,LABORATORY NAME <br />MPliG'FIRMt iA <br />S4I,;, <br />�i��t.k.:,�.^`"'�..Y,�,,:.r"�U^.I"ur�1�(�il�!"1•�!411I!71!lMl!�----_.._.._.______..._.__.-----I <br />TANK ID l' TANK SIZE <br />r, ly- <br />t' 39_----��� ----------- <br />39- <br />- <br />-------------'� ----= <br />;39— -------- — - — — — — — — — — — — — — — — ----- _ _— <br />f , t� <br />PHONE 9 <br />C , <br />'1 Cr; LICCOMPA <br />............... ....... .WOR ........... <br />PEf;M[T , _ <br />PHONE 9 <br />3vh.`...:.Ft nf'.1.tr_s/'Y.- tV6 <br />SAMPLING METHOD vYco�n r�,nYu. w�z�,-,int �K <br />CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSL ! <br />---------------- <br />a ------------_--_— _ _— __ __--_ _ <br />LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br />w.. <br />tirEt,�119"i!iri tlIIIVpIIkII uIWIUUItk°IllLUUUI I�IDJ1U�111111V;11b«!VUBiIIIHUGBLIIgVVUVI9UDui�IUIUGIU�IVHHLiUV �11V➢11U9U'31�!ClhullV! 1'QV!�lu�J�G { 11 C r 9k"� tom' i>Vlh I <br />APPROVED APPRO'r'ED WITH CONDITIONS DISAPPROVED C' <br />(SEE ATTACHMENT WITH CONDITIONS) <br />NAMEDATE <br />-<��--/N----- <br />-------------------------------- ---- <br />----------- <br />.� ", '... H'.W...,:�sl:s.1�'?t`:<ti:�!6;Jk:!:!a:�l'w(wUUWt9i'ill:'L`Pli31i:0111'IIWI�'I!.II�iUWIU;IIIJ!VU4DI!CI'IUCJIICllI1VlU!U!1✓IVill�Ji{lllUllilwi➢UIUIIIUIVIVIUCIVJIIUiIUUJI�VI'VI��!! �ltikCllllL•",I' " ,BxU;l;Str'V"�i}:IU!Yl'I�yt ".'r" ' � - i <br />11UST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br />i OF T�F, Aill JOAQJlli LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLO!•JING: "I CERTIFY TfIAT ,F <br />t IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL. NOT ENPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br />ll?J1�T Tl,9);1R9ER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I� <br />t FOLLOfdI "I LF.RTIFY;rIil41' IM SME FF-f;FORIANCE OF THE WORK FOR WHICH THIS PERMIT I5 lSSUEDI I SHALL EMPLOY PERSONS SUBJECT f <br />TO 0RKER'S COMPENSATION LAWS OF CALIFORNIA, <br />C :I_I_ FOR IN'_3PECTIONS AT 1_E.A ST 113 HOLJRS III ADVANCE ! <br />SI&f"�0 <br />DATE <br />_ <br />------------------------••---------•-------------_ <br />OFF.W- 113 23----- <br />' gS'#`53tf� f�iSSSS3•SS5�iS534SS+3iix#Sf#SSfii#f3ISSi#SS#xSS#S�iS$f#S.5f#5if$#i#5#btS5SSS553rSSS###'x5SS5i#SS#1:#i4�iSi5fi#iSfS <br />ya �rDS ' GDI`,P # LOC CODE DISI CODE AIIIJNT UE Air 'JC'iD I KI/ ASh rC!�0 Y DA' E RCC FCRMIT 1 i <br />}r f I I S (� <br />, <br />