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y - ttztztxaRtxax�— `xxezexeztxtzexexettrextxestxtrtxezeztxeztxez / <br />t: APPLICATION FO"ERMIT t. SAN JOAQUIN LOCAL HEALTH DISTRICT t; <br />t: UNDERGROUND TANK * 1601 E HAZELTON AVE., STOCKTON CAt; <br />t: CLOSURE OR ABANDONMENT t: Telephone (209) 468-3420 t; <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANC��FTORAGE TTY <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />Z REMOVAL ----- TEMPORARY CLOSURE ABANDONMENT IN PLACE <br />EPA SITE f PROJECT CONTACT 4 TELEPHONE i-- <br />L <br />F FACILITY NAME Ae � o o'AcL , crus <br />A PHONEf O <br />ADDRESS <br />1 n n I <br />L CROSS STREET <br />I <br />T OWNER/OPERATOR <br />PHONE i <br />Y �f L <br />C CONTRACTORNAME <br />0 <br />PHONE i O <br />6 _ <br />N CONTRACTOR ADDRESS <br />I S <br />CA LIC i <br />O5' O <br />CLASS <br />R INSURER <br />A __�r i• n 2 i y� YORK. COMP. B O F, <br />C FIRE DISTRICT PERMIT i/[NSPTR _ 4 <br />T 11LfLL <br />0 LABORATORY NAME , �—� <br />PHONE i <br />R - 0-9 <br />SAMPLING FIRM* MPL TH <br />T TANK ID i TANK SIZE HEMICALS STORED CURRENTLI CHEMICALS STORED PREVIOUSL <br />A----------- <br />r A. <br />N 39 LY 31e V't <br />- - -- <br />K 39-__=---- <br />39-_,]_ le 3,/ <br />_ <br />_�----------- <br />---------- <br />39 --------------------------- <br />LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br />P __ APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br />L <br />(SEE ATTACHMENT WITH CONDITIONS) <br />Q <br />- <br />_`-------------------------------------- <br />A PLAN REVIEWERS NAME DA1E_I _- F�-;AND <br />N --------- <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RUULATIONSOF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: I CERTIFY THAT <br />IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />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 />'I <br />,-OLLOWING: CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br />CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br />6NEU- --- - ---- ---------------------------------------------------------DATE -- - ---- --- -- - - - <br />iiFltf USE ONLY --EN 13 016 12188 <br />EffPlfffi fffffftfffffLff9ffffDfEffIfffiffffUfEfffAfffffTffDfUfifffAffOfUfNffTfiCfVfDfffffffqf�ffffffffiCffpffBfY9 f�ff4ffffffff�fff�ffftfffffwfRfvffPERMIT ff2fff <br />