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t tx tx ti" it it tYtit tYit.a it mr.tLit:it It:it tv.It cx it:It tx+iAtx tv V.it <br /> r APPLICATION FOR PERMIT k: SAX JOIQUIN LOCAL HEALTH DISTIICTk: <br /> p: UNDERGROUND TAN[ p: 1601 E RIZELTOR AVE., STOCKT01 CII: <br /> I: CLOSURE OR 111NDOUXEIT p: Telephone (2691 168-3120 p: <br /> t tf ff It:It It 0 1 tYkY RYItIt.tx�kx�exp tx�kx�kx�kx�tx�tx'exp tx�tx�kx�tx�kx�tx�N�tz trex <br /> 1PPLICITION FOR PERMANENT/?EMPORIRT CLOSURE OR ABANDONMENT II PLICE OF UNDERGROUND HIIIRDOUS SUBSTINCES STORIGE FICILITY <br /> THIS PERMIT RIPIRES 90 DIPS FROM THE IPPROV/L BITS, DO NOT WRITE IN 111 SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> -k/REMOYAL TIMPORARY CLOSURE _ IBLIDONMENT IN PLICE <br /> EPA SITE i PROJECT CONTICT A TELEPHONE 1 <br /> F FACILITY MAKEPHONE 1 <br /> A .20 — q3/ — 22 cr <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPBRITOR PHONE 1 <br /> T L,„ f7 4 -?o <br /> C CORTRIC?OR NAME PHONE I <br /> 020 r7- �S <br /> T CONTRACTOR <br /> 10DRBS9 <br /> O CA LIC I S6 r C615Sr 91 <br /> i1 <br /> 1 IKSURER WORK.COMP.I G <br /> C FIRE DISTRICTPERMIT I/IXSPTR <br /> 1 Sa o � ,7/ <br /> RLIBORITORY NINE LAS PRONE I� — <br /> SAMPLING FIRM' k SINPLING METHOD <br /> C G a <br /> ?INK [D I ?III SITE CREMICILS STORED CURREMIL CREME LS STORED PREVIOUS!,T � q � C�cY <br /> 1 J9-_._J_1�� ��_ 00 ro� <br /> Y 39- <br /> [ 79- <br /> J9- <br /> 39- <br /> LIST ADDITIONAL TIN[ INFORNIfION AS NEEDED ON SEPARIT6 FOR <br /> tm'J�6l. <br /> P APPROVED _IPPROVND WITH CONDITIONS _ DISAPPROVED <br /> L (SE TIT/CIMENT WITH COXDITIOIS) <br /> / PLAN REVIEWERS MINE <br /> N <br /> IPPLICINT RUST PERFORM ILL WORK IN ICCORDINCE IITH SIX JOIOUIR COUITT ORDININCES, STITH LAWS, IND RULES IND REGULl1IOUS <br /> OF TOR SIN JOAOUIN LOCAL HEALTH DISTRICT. OVXER OR LICENSED ICENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE YORK FOR VOICE THIS PERMIT IS ISSUED, I SMILL NOT EMPLOY INY PERSON IK SUCH XIWNER IS TO BECOX <br /> SUBJECT TO WORKER'S COMPENSATION LITS OF CALIFORNIA.' COBTRICTOVS HIRING OR SUBCONTRACTING SIGKATURE CERTIFIES THE <br /> FOLLOWfIG: 'I CERTIFY ?HIT IN THE PEEFORKINCE OF ?116 1091 FOR WHICH THIS PERMIT 11 ISSUED, I SHALL EMPLOY PERSONS SUBJBC <br /> TO YORKER'S COMPENSITION LIES OF CILIFORIII. <br /> CALOR INS CTI S AT LEAST 40 110URS IN ADVANCE <br /> SICX6D DATE Q — <br /> OFFICB USB ONLY--EH 23 016 12/11 <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SFREPS 1 I COMP IILOC CODE DIST COOq IKOUNT DUE AMOUNT RCVD CKI/CISH RCYD BI DATE HCVD PERMIT I <br /> � q 9 �,3a�, I %D� t U <br />