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et:rLCATOrxt' txERIextttx:x�AtxOQIexOAtxELTHDS ee ORIGINAL <br /> F APPLICATIO 'R PERMIT � SAN JOAQUIN LOCAL HEALTH DIS T <br /> L: UNOERGROY:7 TANK. �: 1601 E HAZELTON AVE., STOCKTON CA <br /> 1: CLOSURE OR ABANDONMENT t: Telephone (209) 468-3420 t: <br /> 1:ff1x:x la:n:Lr:u:n:n:nt-.. tn:n:n:.........r....n.... .......... <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _ REMOVAL _____ TEMPORARY CLOSURE ___- ABANDONMENT IN PLACE <br /> EPA SITE 1 e Ud p 7 a 613, PROJECT CONTACT { TELEPHONE 1 fde2�y <br /> 0704 - Sag 02690 <br /> F FACILTfY NAME �L Cbel-?70 /A/Ke�jr/"&,ejr5 PHONE t N/A <br /> ADDRESS <br /> I .4' COn1�7j2vCTconJ �LRZA j�3 �' ey- <br /> L CROSS STREET I�VBBAR� �H/J <br /> I <br /> T OWNER/OPERATOPHONE t <br /> Y �L Q1aQu /N✓E-STm6nJ r1 0'�9 -5pq- 0 690 <br /> C CONTRACTOR NAME PHONE t Of�I �Zy _G LOS 3 <br /> 0 <br /> N CONTRACTOR ADDRESS Iq ryU)xP�o CA LIC t ggq%q CLASS C-5 <br /> R INSURER - �� � WORK.COMP.I (��osS� <br /> C FIRE DISTRICT 0j,9 pU/p 00 PERMIT t/INSPTR <br /> T -_—'__-- -- <br /> R LABORATORY NAME �9c�f �j,4,re� 4,9,6 PHONE 1 5a`7_ 4/c ,5-D <br /> SAMPLING FIRM+ � ��, 4-fA-r 2 LA B SAMPLING METHOD <br /> T TANK 10 1 TANK SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSI <br /> 6 omg <br /> A 39- Z 2 3� "0 Z, _ /f.T�` L- <br /> N 39 roi Dna 61AI G <br /> K 39 <br /> 31- <br /> 39 <br /> '-----'-------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P APPROVED __APPROVED WITH CONDITIONS DISAPPROVED <br /> L ,pQ (SEE ATTACHMENT WITH CONDITIONS) / <br /> A PLAN REVIEWERS NAME �_1�1w '�4-----------------------------------------DATE__{ Ll�C - - <br /> N - ` <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: Of CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CA F �RINSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED-3O E __ <br /> - <br /> OFFICE USE NLK--EN IJ 016 11/88 <br /> fffftfiffftffifffftfffffftf{ffftfffffff{ifffffffffifffftt{tifffflffififfiftffffS{ftfffftt{fft{f{iftft{{fffffttftft{{fffff <br /> SWEEPS t I COMP t LOC CODE DIST CODE1 AMOUNT DUE I AMOUNT RCVD I CKI/CASH I RCVD BY DATE RCVD PERMIT 1 <br />