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Btk C}a}: R: t t}'t$tt CY m: ft ti, R. t}: tI: R. tk: VI: tF tk: t}: R, III: tY tv R: t8 tti t-i'k: tkak APPLICATI POR PERMIT r SIN JOAQUIN LOCAL HEALTH 0 1CTt: t: UNDERLwD TANK t: 1601 E HAZELTON AVB., STOCK CA t: A u CLOSURE OR 111HOONXEIT t Tel(209( 168 )120 t E lk: tk tk: L'k FC: Ck Fk L'k' CGL'1'�l't'} Ck tk l'fi tk tBtl'tk L"t tt t}: tG L''C Fk tk: tk. tk: tl: FSfftI: tv 1PPLICITION FOR PERMINEYT/TEMPOURY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY THIS PERMIT EMPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT FRITS IN III S11010 AREAS. INDICATE PERMIT TYPE BELOW: I'RRENOYAL --__ TEMPORARY CLOSURE IRMAMMI tv oilro SIXPNIL180TDRI NINE PHONE R=��c—��-.�_5: LIYc FIRM' Ym. . m.0 .m . . .......... .s J..l`.�..�:' f 05 W SAMPLING METHOD Tax ID I T 1 1T -1S /s ? [ ID- TIME SIZE CHEMICALS STORED CURRENTLI CHEMICALS STORED PREY[ LIST ADDITIONAL TANK INFORMATION AS NEEDED 09 SEPARITN PORK .......................... . . _ - - -. - — •_.-.._.-..........w..n.mwYYi ryumuuiWWYYYIYYYYYYY P ✓APPROVED _ APPROVED WITH CONDITIONS DISAPPROVED L SEW ATTACHMENT WITH CONDITIONS) 1 PLAN 11111,11, NAME —_� APPLICANT MUST PERFORM ILL YORK IN ACCORDANCE WITH SAH JOAOUIH COUNTY ORDINANCES, STATE LAYS, NANDRULES IND REGULATIONS OF THE SAY JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY TN1T IN THE PERFORMANCE OF AHE YORK FOR VHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON 1N SUCH NAYNER IS TO MON' SUBJECT t0 YORKER'S COMPENSATION LIES OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNITURE CERTIFIES THE FOLLOVING: 'I CERTIFY THAT If THE PERFORMANCE OF THE YORK FOR VHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC' TO YORIEV S COMPENSATION LIES OF CALIFORNIA. CALL F/O� INSPEC1 AT,,PEAST 48 HOURS IN ADVANCE SIGNED_ DATE�2-��/ OFFICE USE ONLY X23 016 12/11 ---- SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSFSSSSSSSSSSSSSSSSSSSSSSSSSS SWEEPS I COMP I LOC CODE DIST CODE INOUNT OUR AMOUNT HCVD I CKI/f ASN I RCYD BT I DATE HCVD PERMIT 1 EPA S[t8 I CA --0001179-33 PROJBCTlCONTACT d TELEPHONE I P I P1C[L[Tf NAME �PNONE 1 L: t F t- nQ_� _- 9Y5�=yo 7_—_-- C ADDRESS L CROSS STRYKT 11 T OVYER/OPERITOR PHONE I f J/078 -- C 0 CONTRACTOR MIME PHONE ! {eop e Y T 7339- iecpe CONTRACTOR ADDRESS /� Cd LIG I C1 LIC CLAS 3 Cw CLAS ", l�s2o _ /�y�s� R I INSURER /� S WORK. COMP,I _ �-��- C T FIRS DISTRICT --!/[NSP I-',f•.�— Ji2 +• 1 PERMIT TR SIXPNIL180TDRI NINE PHONE R=��c—��-.�_5: LIYc FIRM' Ym. . m.0 .m . . .......... .s J..l`.�..�:' f 05 W SAMPLING METHOD Tax ID I T 1 1T -1S /s ? [ ID- TIME SIZE CHEMICALS STORED CURRENTLI CHEMICALS STORED PREY[ LIST ADDITIONAL TANK INFORMATION AS NEEDED 09 SEPARITN PORK .......................... . . _ - - -. - — •_.-.._.-..........w..n.mwYYi ryumuuiWWYYYIYYYYYYY P ✓APPROVED _ APPROVED WITH CONDITIONS DISAPPROVED L SEW ATTACHMENT WITH CONDITIONS) 1 PLAN 11111,11, NAME —_� APPLICANT MUST PERFORM ILL YORK IN ACCORDANCE WITH SAH JOAOUIH COUNTY ORDINANCES, STATE LAYS, NANDRULES IND REGULATIONS OF THE SAY JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY TN1T IN THE PERFORMANCE OF AHE YORK FOR VHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON 1N SUCH NAYNER IS TO MON' SUBJECT t0 YORKER'S COMPENSATION LIES OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNITURE CERTIFIES THE FOLLOVING: 'I CERTIFY THAT If THE PERFORMANCE OF THE YORK FOR VHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC' TO YORIEV S COMPENSATION LIES OF CALIFORNIA. CALL F/O� INSPEC1 AT,,PEAST 48 HOURS IN ADVANCE SIGNED_ DATE�2-��/ OFFICE USE ONLY X23 016 12/11 ---- SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSFSSSSSSSSSSSSSSSSSSSSSSSSSS SWEEPS I COMP I LOC CODE DIST CODE INOUNT OUR AMOUNT HCVD I CKI/f ASN I RCYD BT I DATE HCVD PERMIT 1