Laserfiche WebLink
tt: A LLTH DI <br /> IGATION FOR PERMIT t; SAN JOAQUIN LOCAL HEASTRICT K <br /> UNDERGr' "HD TANK f 1601 E HAMILTON AVE., STOCK' ' CA <br /> t: CLOSURE i _JANOONMENT t; Telephone (209) 468-34, <br /> r• <br /> APPLICATION FOR PEfWIUINY/PtT1941Y CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAIARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRERW 15hhYF INNER APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> 14 AY 1 � 166AL _ TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE 74qY0NOE J � }� a PROJECT CONTACT f TELEPHONE t y}� �)�Ti9/�ILSY /� ATT/1fJ✓S <br /> F FACILITY FrC ✓NO[E G'o,QP PHONE ta �A 9- 9,vo - 0600ADDRESS /jrRIg(/ ✓e o c�Grn <br /> L CROSS STREET ,J/�PO <br /> 1 1,41 <br /> / <br /> T OWN/ /ER/OPERATOR PHONE f <br /> Y (//T// xjEles/-�-L- ✓n/ _� E �/�P — - - 2O�=�a - 0_6 0 0___ <br /> C CONTRACTOR NAME PHONE t — <br /> D —_�exrc ao�( - Z14 - g653 <br /> N CONTRACTOR ADDRESS)431 (,J VWwV) �� j �v CA LIC j4ggq Qy CLASS <br /> I <br /> bI <br /> R INSURER <br /> �� rm; Zh5_ WORK.COMP.t ���5 <br /> TFIRE DISTRICT i �, PERMIT t/INSPTR <br /> 0 LABORATORY NAME <br /> R PHONE 1 6&)7 - Z710 S <br /> f� <br /> SAMPLING FIRMF (?Q L/�. !,/A ]� 2 i[A g SAMPLING METHOD <br /> TANK ID t TANK SIZE CHEMICALS STORED CURRENTLI CHEMICALS STORED PREVIOUSL <br /> T <br /> A 39 �-� --� ---------- �� /✓/i9 <br /> N 39 xlS -= -�---------- <br /> K 39 _ <br /> 39---------------------------- <br /> 39 --------------------------- <br /> LIST ADDITIO TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P --__ APPROVED __APPROVED WITH CONDITIONS DISAPPROVED <br /> V (SEE TACHMENT WITH CONDITIONS) _ <br /> A PLAN REVIEWERS NAME ----1,-z�__ ---------------------------------DATE <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: '1 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 BECOM <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, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL SPECTIONS ALEAST 48 HOURSIN ADVANCEDr��77 pp <br /> SIGNED--- ..!_/il_---------------- <br /> $0$11011111100 <br /> 0 / <br /> OFFICE US 0 Y--EH 13 OY6 11/8B <br /> -=--- ------------ <br /> ffffiffffftf{{fffffffff{f$0$11 fi111100{ffiffiff{fffffff{ft{fgf�fyfffifffffffffffffffffftifffifffffffffffffffifffiffffffffff <br /> SWEEPSt IIlAMV24t{LOC CODE IDS ))DEI t MONOOE I /M�l1ETD I/(Au ASH I�fpQ a DA E RCVD ---PERMIT t <br /> 36r `6U I<1�71C. <br /> l <br />