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eaki.aft"tic R.,ki.ITk1 tn"mti.tfi'Vi.tvti.tvti.ti.ti,ati.att*.att:tm <br /> e APPLICITION POR PERMIT w SAN JOAQUIN LOCAL HEALTH DISTIICTk: <br /> k: UNDERGROUND TAN( t: 1601 B HIZELTON AVE., STOCK?0N Clk: <br /> k: CLOSURE OR ABANDONMENT a Telephone (209) 168-3120 k: <br /> t ti tfi�ki�Ci�Rfi�tfi�tfi�tfi�ki�tfifi�tfi�tfi�tfi�tfi�tk tfi�ti�kfi�Ci�kfi�ti�tfi�kfi�Ci�tfi�ki�ti�ti�Ci�ti�ti�ti <br /> APPLICATION FOR PERMANENT/TEMPORIRT CLOSURE OR ABhIDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EKPIRES 90 DAYS FROM THE APPROVIL DATE. DO NOT IIITE IN 111 SHADID AREAS. INDICATE PERMIT TYPE IBLOW: <br /> REMOVAL _ TEMPORARY CLOSURE — ABANDONMENT IN PLACE <br /> EPI SITE t PROJECT CONTICT K TELEPHONE I s r <br /> �-hC - ooc)ar�31L-3 <br /> F FACILITY 1A1e ; PHONE I <br /> A <br /> ADDRESS �_FZ C�19 <br /> 1 <br /> LCROSS STREET - <br /> I <br /> T OWWBR/OPBRITOR. PHONE I <br /> T <br /> C CONTRACTOR WANKPHONE t <br /> 0 <br /> 2 <br /> 1 CONtRICTOR IDDRIS3 % CA LIC 1 / ' n j CLISS�• �_ <br /> I INSURER <br /> CFIRE DISTRICT �' i PERMIT 1/IHSPT1 <br /> I <br /> 0 LABORATORY NAME <br /> R <br /> SAMPLING FIRM' SAMPLING SAMPLING METHOD <br /> TANI ID�1 TINK SIZE CHEMICALS STORED CURRENILI CHEMICALS STORED PRIVIOUSL <br /> 1 39 - <br /> Y <br /> 39- <br /> 39- <br /> 39- <br /> 31- <br /> LIST <br /> 9-39-39- LIST ADDITIONAL TANK INFORMATION 19 NEEDED 01 SEPARATE FORK <br /> uwuuKlrN�um DNwuwwwwmiwuiiawt�uBDiNw�w�RwwwBu�NwuwusuuruiBwwwuuwuyuyruw;aww�uAuawiuwiDtwlut;DwwHutwDiiwuD�wnwNulwmitwnNuuwu�KNUDu <br /> P �/_ APPROVED _APPROVED WITH CONDITIONS _ DISAPPROVED <br /> L (SBR ATTACUMINT WITH CONDITIONS) <br /> I PLIN REVIENERS NIMH _- _^---DATE- <br /> N T <br /> IPPLICANT MUS? PERFORM ILL WORK IN ACCORDANCE /ATH SIN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES IND REGULATIONS <br /> OF THE SAW JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY ?flit <br /> 11 THE PERFORMANCE of THE WORK FOR WHICH THIS PERMIT 19 ISSUED, I SHILL NOT EMPLOY ANY PERSON IN SUCH EITHER AS TO BECON <br /> SUBJECT TO WORKER'S COMPBISITION LAWS Of CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY ?HIT IN TER PERFORMINCE OF AHE WORT FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKBR'S COMPENSATION LITS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 40 HOURS IN ADVANCE <br /> SIGNED_ 11�t l�� �1� DATE �, 0�� <br /> OFFICE USE OHLY•:dll 17 016 12/11 <br /> SSSSSSSSSSSS'rSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS!SSSS <br /> s�ios=_ M i LOC CODE 1I 7-CODE' AMOUNT Dt I- ANcIN�t RQ� I- CKI/C�AS�O-I� = g ,?, R - PERMIT 1 <br />