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1:ft tr ka:t:v tl�ti:tit ti:it:ft tv.it:kt.tl:tt.ti:it:ty ft it:t"l,tot:it:ti,ti:it: <br /> APPLICATION FOR PERMIT 311 JOAQUIN LOCAL HEALTH DlStRICTk. <br /> UNDERGROUND TANK 1601 1 HAZILTON AVB., STOCKTON Clf. DEC 8 1539 <br /> CLOSURE OR ABANDONMENT G Telephone (2091 168-3420 t: <br /> t:ki:ti:t t it:k gl ti:it:t t it:tit:L t:ti:ft it:tic till:k t:ff it ki:ft it:kis it:it:it:it:tt:ti:ffhN v F� EN TA L <br /> PERMIT sER': iCEs <br /> IPPLICITION FOR PERMANENT/TEMPORIRY CLOSUII OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DIYS FROM THE APPROVAL BITE. DO NOT V1178 IN III SI1hDID AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABINDONMENT IN PLICS <br /> EPA SITE I PROJECT CONTICT 4 TELEPHONE <br /> P FACILITY NAME LCC)�k�n) Ay 00y PUONE lam <br /> A L- I al Lq q <br /> CADDRESS <br /> I �3 Union 5L. <br /> L CROSS Still? <br /> I <br /> T OWNER/OPERATOR PHONE I <br /> C COVTRICTOR N1 MEPHONE IZIAqv- 4?&56 <br /> I CONtIACTOR ADDRESSCA LIC 1 CLASS <br /> T <br /> I I NSUR III -—co K—P I rag 5y s15= <br /> C FIRE DISTRICT PERMIT I/Imspya <br /> I <br /> 0 LABORATORY WARR PHONE I <br /> R <br /> SAMPLING FIRM' (q l SAMPLING RETXODja <br /> TANK ID I TIKI SIZE CHEMICALS STORED CURRINT6 CHEMICALS 510190 PRIVIOUSL' <br /> T <br /> A 1 A <br /> 39- ctp dd <br /> 139- <br /> 39- <br /> LIST ADDITIONAL TANK IMFORNITION AS NEEDED 09 SEPARATE FORK <br /> P IPPiOVED _APPROVED WITH CONDITIONS DISAPPROVED <br /> L (SEE ATTACHMENT WITH CONDITIONS) <br /> I PLAN REEIVERS MINI <br /> IPPLICANT MUST PERFORM ILL WORK 11 ACCORD/NCE WITH SAN JOIQUIN COUNTY ORDINANCES, STATE LIVS, AND RULES LED REGULATIONS <br /> OF THE SIN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 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 YORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRI1C OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR Vfl[CH THIS PERMIT 15 ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPOSITION LIVS OF CALIFORNIA. <br /> CALL -FOR IN�S�PEICTION AT LEAST 40 HOURS IN ADVANCE <br /> OYFIC9 USE ONLY-411023 046 12181 <br /> SWEEPS—I COMP I � LOC CODE j 0151 CJOXOUNT DUE AMOUNT RCVD CXI/CASII 10BY Dill RCVD PERMIT I <br /> ---------- <br />