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IPPLICITIOI FOS PERMIT SIR JOIOUIR LOCAL HEALTH DISUIC% <br /> UVDRRGROUID TANK 1601 0 HIISLTOX AVE., STOCKTON CA <br /> CLOSURE OR LOINDOMMENT Telephone (209) 468-3420 <br /> IPPLICITION FOR PRRHARRIT/TEMPORIRT CLOSURE OR IBIIDONMENT IN PLICR OF UNDERGROUND HIZIRDOUS SUBSTUCES STORIGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL BITE. DO NOT WRITE IN III SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> RIKOVIL TEMPORARY CLOSURE IBIVDONMRNT IN PLICI <br /> EPA SITE I C ,q c: 0 00 00,1 PROJECT CONTACT L TELEPHONE I f- H <br /> T- F— P, <br /> ?23-76 314 <br /> � <br /> F FICILITY NAME QPHONE 1 r23-7G 3q 2-7a <br /> C ADDRESS 7,eq <br /> "V C,t4S �,p <br /> I -- ,1,9_�_ <br /> L CROSS Still? <br /> I --- ss P-,,n 4 v <br /> 7 OWNER/OPERATOR PROVE I eF� 3 —763L( <br /> C CONtRICTOR NINEL-L 4F-,H/a- PHONE I <br /> 0 3— 7 0 <br /> I COKTIICTOR IDDIESS �ff Mp PZ_,,�cic- CA LIC I CLASS <br /> T ---- -- � I — <br /> I INSURER WORK.COMP.1 <br /> A =_= - -- <br /> C FIRS DISTRICT L/-I Mpg ry aq r- ✓ -/L/7- PERMIT 11[MSPIR <br /> 0 LIBORITORY NIKE f/f lij totV I 1= 3 40 <br /> I <br /> SAMPLING FIRMS on-ei o t' e. SAMPLING METIOD f <br /> 6r—, 5_, —7 <br /> TANK ID I ?INK SIZE CHEMICILS STORED CURRENTLI CHEMICILS STORED PRIVIOUSL <br /> ? <br /> go /J fq/VjE- C4-5 0 's- <br /> 1 39-—-—-— <br /> MST ADDI�TdIL IINK INFORMATION AS NEEDED 01 SEPARITE FORK <br /> 10 N WaD <br /> I HOW <br /> I IF ....... <br /> P APPROVED L,-APPROVED V[fH CONDITIONS DISAPPROVED <br /> L (SRI ATTACHMENT WITH CONDITIONS) <br /> I PLIN REVIEWERS MINE <br /> I <br /> uwam tllmYDmmmmummmmtlmlmmNmlmNmBmYmtlm <br /> APPLICANT MUST PERFORM ALL WORK IN ICCoRDINCI WITH SIN JOIQUIM COUNTY ORDINANCES, STATE LIPS, AND RULES IND REGULITIONs <br /> OF THE SIR JOAOUII LOCAL HEALTH DISTRICT. GIVES OR LICENSED IGENTIS SIcjjTUgj CERTIFIES THE FOLLOWING: 'I CERTIFY TUIT <br /> 10 TER PERFORMANCE OF THE VORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL 101 EMPLOY ANY PERSON IN SUCH HARRIS IS To BECOMI <br /> SUBJECT To YORKER'S COMPENSATION LAYS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY THAT 11 THE PERFORMANCE OF THE VORK FOR VOICH THIS PERMIT is ISSUED, I SHALL EMPLOY PERSONS SUBJRCI <br /> TO WORKER'S COMPENSATION LIVS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED <br /> OFFICE USE ONLY <br /> Si 23 <br /> 46 <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SVIRPS I I COMP I I LOC CODE I DIST CODI INOUNT OUR I AHOUIt RC VD- CKI/CASH I RCVD BY I BITS RCVD <br />