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APPLICITION FOR PERMIT SIR JOAQUIN LOCAL HEALTH DISTRICTk: <br /> UNDERGROUND TANK 1601 8 HAIRLTON IVR., STOCKTOI CAV. <br /> CLOSURE OR 11INDORKENT Telephone 12091 468-3420 t: <br /> rrtRktktIV R:ft:ti:R:M:R:R:k1:ki:11:ti,ti:t V ev R tv t1l:it:R:ff kill:R:ti,R:ff R: <br /> APPLICATION FOR P[RHANRWT/TEMPORIRY CLOSURE OR ABANDONMENT 11 PLACE OF UNDERGROUND HAZARDOUS SUBSTINCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL D178. DO NOT VII?R IN III SHADED AREAS. INDICATE PERMIT TYPE IRLOW: <br /> 4---REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLICI- <br /> EPA SITE I C8C 020 PROJECT CONTICT A TILRPHO <br /> HE L <br /> F FACILITY MIME PHONE I <br /> A <br /> C ADDRESS <br /> I ---- , I-)-Iz!� .9,4 -s & -� /f/,�d <br /> L CROSS STRUT <br /> u 12 ta. <br /> J <br /> I OWNER/OPERITOR PHONE I <br /> AL ........... <br /> C CONTRICTOR MIKE PHONE I <br /> I CONTRACTOR ADDRESS all a L a CA LIC I6" CLIS!�--- <br /> ---- <br /> R INSURER WORK.COMP I <br /> C FIRE DISTRICT I PERMIT I/IMSPTR <br /> 7 )h oil /GP Z(j 61AEz r-4F L)" <br /> 0 LABORATORY MIKE f� <br /> PHONE1 ,,?,17 -47ya <br /> SIMPLING FIRM' yn G --LSIMPLING METIOD <br /> TANK 10 A TANK SIZE CHRMICILS STORED CURRENTLI CHEMICALS STORED PREVIOUS <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED 09 SEPARATE FORM <br /> P APPROVED —APPROVED WITH CONDITIONS -- DISAPPROVED <br /> LM ENT WITH CONDITIONS) <br /> I PLAN REVIEWERS HINZ _aAlte ATTA DATZ_ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SIN JOAQUIN COUNTY ORDINANCES, STILE LAWS, AND RULES IND REGULITIONS <br /> OF TUR SIN JOAQUIN LOCAL HRILTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED, I SHALL NOT EMPLOY IVY PE2301 IN SUCH MANNER AS TO BECOMI <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: ml CERTIFY ?HIT IN THE PERFORMANCE OF ?MR 1021 FOR WHICH THIS PERMIT 13 ISSUED, I SHALL EMPLOY PERSONS SUBJRCI <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED <br /> OFFICE USE ONLY--8H 23 046 12181 <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS I COMP I LOC CODE IDIST CODR� AMOUNT Dug � 55CASH RCYD BY D�7? RCVD-- PERMIT I <br /> A5 <br />