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o-wt�t�nz erextxexare:a�tttre�wtotoe�extl;�txtzextxwe8'cutoexezee� <br /> APPLICATION FOR PERMIT K SII JOAQUIN LOCAL 1EALTV DISTRICTt: <br /> C UIDER(ROUID TAYl t: 1601 E HAE6LT01 AVE., STOC[T01 CAB <br /> c CLOSURE 01 1I1100YMINT t felephoee (201) 468-3420 t: <br /> t el trtt'tt extt�tl e�tl etl�tZte tt tt tt t;tt txe;wt:'e;trtt�trtt e�trtrtret'er <br /> APPLICATION FOR PBRMINRIT/TBMPOURT CLOSUII OR ABANDONMENT 11 PLACE OF UNDERGROUND RISIIDOUS SUBSTANCES STOIIGR FACILITY <br /> THIS PERMIT RIPIRRS 90 DAYS FROM THE APPROVAL DATE. DD NOT WRIT[ IY 111 SHADII AREAS. INDICATE PERMIT TYPE IELOM: <br /> X REMOVAL TBMPOHARY CLOSURE _ 1811001MKIT IN PLACE <br /> IPI SITE I f6gc TELEPHONE I William <br /> NTazKJ <br /> F P1C[LIfT N►M6 <br /> a Fbnmer 1�ocon Station No. 7-1050 PHONE 1 415-246-8752 <br /> ADDRESS <br /> 1 909 West Hamner Lane <br /> 1 <br /> L CROSS STREET <br /> 1 Lir Sacramento Road <br /> T OYMBR/OPERATOR PHOMR I <br /> I Kaon Company, U.S.A. 415-246-8752 <br /> C CONTRACTOR NINE Don Lambert 6 Sons PHOYR 1 209-874-2168 <br /> 0 <br /> 1 CONTR <br /> 1 ACTOR ADDRESS 121 "F" Street,Waterford, CA Cl LIC 1 561566 CL13S A <br /> I INSUIBI YORI.COMP.I -rently on file <br /> e <br /> C FIRE DISTRICT /l'b. R 9uinc� PERMIT I/IYSPTR <br /> 1 <br /> 0 LIBOR <br /> ATOIY MINE Applied Analytical PHONE 1 916-452-2901 <br /> R <br /> SAMPLING FIIM' SAMPLING METIOD <br /> TAPE ID I fill SIZE CHEMICALS STORED CL'R1111L CHEMICALS STORED PRIVIOUSL <br /> T <br /> 1 39- P1Pi-n4 O/1 1 Pi None Regular Lead Gasoline <br /> N 39- Unleaded line <br /> 1 39 Unleaded line <br /> 39- <br /> 39- _ <br /> LIST ADDITIONAL TAXI <br /> INFORN/TION lS NEEDED 01 SEPARATE FORM <br /> P APPROVED _APPROVED WITH CONDITIONS _ DISAPPIOFED u'e <br /> LB /T1ICUMRYI WITH CONDITIONS) <br /> 1 PLAN RBFIIYRRS MIME Dirt��,�� <br /> Y � <br /> APPLICANT MUST PEIFORM ILL fall 11 ACCORDANCE MITI SIN JOAQUIN COUNTY ORDINIMCBS, STATE LAYS, IND RULES 110 REGULATIONS <br /> OF THE SIN JOAOUIM LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOUNG: 11 CERTIFY THAT <br /> IN TNR PERFORMANCE OF THB MOIl FOR WHICH THIS PERMIT IS ISSUED, 1 SMALL NOT EMPLOY III PERSON IN SUCH M11111 IS TO BECOM <br /> SUBJECT TO YORIEI'S COMP91SITION LAYS OF CILIPOINII.' CONTRACTOR'S HIRING 01 SUBCONTRACTING SIGNATURE CRRTIFIBS THI <br /> FOLLOWING: 11 CERTIFY THAT IN THE PEIFORNIMCB OF 1116 PORI FOR WHICH THIS PERMIT 13 ISSUED, I SHILL EMPLOY PERSONS SUBJRC <br /> TO VORl6R'S COMPENSATION LIES OF CILIFORYII. <br /> CAL INS S AT LEAST 40 HOURS IN ADVANCE <br /> SICY[ OITB � d <br /> Ice 13 016 12/81 <br /> ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss4ssssssssssssssssssssssssssssssssssssssssssssssssssssssss <br /> STRIPS I I CONP I ILOC CODEDIST COD AMOUNT AMOUNT DU[ �lAMOUNT HCVD C[1/CIS1 RC►D IT DIT[ ICVD PERMIT 1 <br /> 4II SC4 01 132-1 I'�qc) Icf" I —)3--EI f�'� /3��a <br />