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k:ti'ki titi: tilt titit ti tv tva a kn"I:ti'ft It;It:n:ti atv ti: tvki:it: <br /> APPLIC/YruN FOR PERMIT SAN JOIOUIY LOCAL HEALTH .:ATE CTj: <br /> p: UNDERGROUND TANK t: 1601 B HIIBLTON AVB., STOCKTON Cit <br /> r CLOSURE OR 11100111117 Y Telephone (2091 168-3120 t: <br /> 14111 ti ti kiti�titfiti�Cifi�ki ki CfiN�ki�tfiCi tY HkitiAti ti ti kfi�ti�ki�ti ti�titi ti <br /> APPLICATION FOR PERMANENT/TEMPORIRT CLOSUIB OR ABANDONMENT IN PLACE OF UNDERGROUND RAXIRDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN 111 SHADED AREAS. INDICATE PERMIT TYPE IELOW: <br /> REMOVAL ___ TEMPORARY CLOSURE — ABANDONMENT IN PLIC' <br /> C 00c .far do <br /> BPI SIT' 1 — PROJECT CONTACT a T66EPHONB I ��-�J ���� <br /> C/Jh c� <br /> P FACILITY NAME— ( _P 1 r PHONE I <br /> I - \T 1 11 u <br /> C ADDRESS `G 1 -1 hac P C LA 1 tA__ <br /> I <br /> L CROSS STREET <br /> T OWNER/OPERATOR PEONS 1 <br /> If <br /> C CONTRACTOR MIM' ��.Id�n � PEOtl6 <br /> J�SQL— <br /> I CONTRACTOR ADDRESS P o CA LIC 1 CLASS <br /> ^�_�=__--� <br /> C FIRE DISTRICT PERMIT 1/INSPTR <br /> o Ll'oRlro'r NAME PNotle I rl2 — Q9CD <br /> R --- <br /> SAMPLING FIRMt C-51f(�]f(IT-1 <br /> CGI �� SAMPLING METNOD <br /> DN4rYWIWu14WWYWIWIIWIkDIIIIIIWkYN11WYWIYIIp11W --- -'-- --'------ _"--'-'-----_-..—. <br /> TANI ID I TIMI SIS' CREHICILS STORED CURRENTL CHEMICILS STORED PRWVIOUSL <br /> 1 <br /> 1 19 �'hciu- n39- LIST ADDITIONAL TANK INFORMITION IS NNEDED ON SEPAR119 FORK <br /> WWNWIIIWIWIiA'YWIIIWIDRtAIW61WGIIItWi!DWWUtW11DWYDDWYYVw!pWWIIIIOHIWIUYDDYlYI�W'WUNIIYDCIIIYIIIWJW!�IWIWWWDW;tWiWDIWWJWID4WW�IWWw"�IWIIY4tWWYWWYLI� <br /> P -__ APPROVED ✓ hPPROVED WITH CONDITIONS DISAPPROVED <br /> L (SEB ITTACUM917 WITH CONDITIONS)- <br /> 1 PLAN REVIEWERS PIKE � ��N ___�_— _ _�—_ DIrE__// (y QD--�—_-- <br /> N <br /> WWWiIYNYWIIYYtlW4DYYtlWWUYWYDYYWWYW INYIYWIYYYYNWWYRYWWWYYWWNWWINYNIYYNYWWWWWWIIWYYWWINWIWYYWRYtlYDNYIIWYWY <br /> APPLICANT MUST PERFORM ILL YORK IN ACCORDANCE WITH SIM JOAQUIN COUNTY ORDINANCES, Sr1TS LIPS, AND RULES IND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORT FOR WHICH THIS PERMIT IS ISSUED, I SMALL WOT EMPLOY ANY PERSON IN SUCH MANNER 1S TO BECOM <br /> SUBJECT TO YORKER'S COMPENSITION LAYS OF CILIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT Itl THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO YORKER'S COMPENSATION LAWS OF CALIFORN[I. <br /> CALL FOR INSPECTIONS AT LEAST 48 H .LIRS IN ADVANCE <br /> SIGNED _ _ DAT' <br /> OFFICE USE OY 23 016 12/AK <br /> SSBSSSS93SSSS SSSSSSSSSSSSSSSSSSSSSSSSS4SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSlSSSS <br /> SYBEP9 I—I—COMP—I �LOC CODE I DIST COOBI—AMOUNT DUE]— AMOUNT RCVD I C11/CASH I--RCYD BY---DATE RCVD — PERMIT 1 <br />