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Iit9Ztit2R2:RRiikYtitu:kiUR8!$ti'ansmanlylikillott itYtYlir�ri'!S _ <br /> r. APPLICATIO,1 '^R PERMIT r SAN JOAOUIN LOCAL HEALTH DIE <br /> t UNDER6k TANK c 1601 E HAZELTON AVE., STOCKTOA-n e `J <br /> r CLOSUkE OR ABANDONMENT f Telephone (209) 468-3420 / �'q <br /> :��::a':�:>:rxl>:IrN::'::�:x:y:a:�:? xn:rr.ncrxn:n:n::';':::narlrrr. C.-� �- <br /> :x �l <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 tA11,7I G QO� PROJECT CONTACT W TELEPHONE tL 09 8352 2 93 <br /> F FACILITY NAME Pescadero Reclamation Dist Wendy <br /> A # PHONE t same as above <br /> C ADDRESS 3650 W Canal Blvd Tracy ( Banta ) CA 95376 <br /> 1 <br /> L CROSS STREET 4 mile East of California Ave . <br /> I <br /> T OWNER/OPERATOR Pescadero Reclamation District PHONE t 209 835 2293 <br /> Y <br /> C CONTRACTOR NAME --- <br /> 0 �2fn PHONE 1 1;�09 <br /> NCONTRACTOR ADDRESS <br /> T 3 ee CA LIC t CLASS <br /> R INSURER q � U <br /> A -- WORK.COMP.t <br /> C FIRE DISTRICT Banta Rural Fire <br /> T PERMIT t/INSPTR <br /> 0 LABORATORY NAME 7 o <br /> R Californla Water Labs . PHONE 1 5�7 5,16� <br /> SAMPLING FIRMk <br /> SAMPLING METHOD <br /> TANK 10 t <br /> T TANK SIIE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> A 39 `1_ � 0� <br /> N 39- e none <br /> ----------------- <br /> K 39 - <br /> -----------39- <br /> 39 <br /> LIST <br /> 9 39LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P <br /> L _} APPROVED __ APPROVED WITH CONDITIONS ___ DISAPPROVED <br /> A PLAN REVIEWERS NAME (SEE ATTACHMENT WITH CONDITIONS) <br /> N ��i!�I __ i�`✓/�----------------------DATE — - <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: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBIEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED /// `f <br /> OFFICE USE <br /> ONLY--fN 23 006 !1/ 8 - - � � -- ��_s�__}_____________DATE <br /> fiffifffiffifffff0f{ff{ffff{fffffifff4f4ffffffffffffffffffffiff{t{ff{ }f(�ffffff{ffffitffff{ffffffffffffffffffffff4if4ff <br /> SWEEPS MP 1 LOC CODE DIST A 011llT pUE AM�� VD I cK1 3H I RCVD BY I �ATERC PERMIT t <br /> / � /� <br />