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-- r <br /> tT'tt'tt" 't#'tVtv tvt;ki:tYtx t;'tt'ti: a tt tfi <br /> k APP__C FOR PERMIT w SIN JOAQUiN LOCAL REALtHR1Ctk: <br /> t. UIDERGROUID TANI t I60I E HIIELTON AVE., STOCK701 CAt- <br /> t- 1NDOIKEIT Telephone 12091 468-3120 t: <br /> CLOSURE OR 19t; <br /> kttfttTffftttktmam: tl'kvkn tv ti:tY fftf tra: <br /> 1PPLICITION FOR PERMARRITIT9001IIRT CLOSURI OR ABAIDONMENT IN PLACE OF UNDERGROUND H1I11DOUS SUBStIWCES STORAGE FACILITY <br /> THIS PERMIT ExPIRES 90 DAYS FROM THE IPPROVIL D1TE. DO NOT 1117E 19 111 SHAD{) AREAS. INDICATE PERMIT TYPE BELOW: <br /> �f RSIIflPbL _ TEMPORARY CLOSURE 16AIDOHMBNT IN PL1C1 <br /> EPI SITY I PROJECT CQITICT I TELEPHONE I <br /> F FACILITY NINE ci =:�] <br /> PHONE I �. — <br /> I <br /> C IDDRESS <br /> 1 --� <br /> L CROSS STR11S <br /> { PHOSE I <br /> I — <br /> C CQITRICTOR 14— / PHONE l�l/,9L <br /> Cl LIC I �- CLASS <br /> I C01TR1CTOR IDDRESS ,3C1 %�I�._—_ 'C _ <br /> R INSURER , WORK,COMP.I <br /> ter G � ��� _ �' <br /> 1 / — <br /> C FIRE DISTRICT , 14 92 4J <br /> PERMIT IIIWSPTR <br /> v <br /> r <br /> 0 LABORITORT NINE � i� � �/� PHONE I � <br /> R - <br /> SAMPLING FIRM' <br /> SAMPLING NETYOD �_ — <br /> f11c�YImi11R��1Ia�11gIH IN�IiNrY <br /> 19- <br /> TIME ID I TANI 511E CHEMICILS STORED CL'RR>ITL CHEMICALS STORED PREVIOUSL <br /> ZI <br /> K 39- <br /> 39- _ <br /> LIST ADDITIONAL TANK IMFORMITIOM AS NEEDED 01 SEPARATE FORM <br /> -- EII lIAIHI k111YIgIW1lIi�IpUlygpgWRqY4�IlYIIqItINN{RHRIpR. IIW!1w9gifillRlilllAf�l'IIIINII�NJi129115l�tilllilJii!Iltl'�'I'L ":Aisll'JILN"w1R',JIIIIIG !IftIIII�IEJu41lJi1Cll:l7'Fr91Ltl3WlU'WiL'�NIkUEIIII�kii191CS11Yi1kLill�lilYlldCllRGi�l'±IIJ'r'II�IIfII�lYJk1 '; <br /> P APPROVED IPPROPED WITH CC901TIONS __— D15APPR04ED I <br /> Li E�ITTANINEWT WITH COHDIV O W <br /> DATE 10 <br /> 1 PLIN REVIEWIRS NINE -- --- ---___ — — `f----------- <br /> I ' <br /> 1 i�tgWIR�YHaiiL"iUI�IR"D'Jbtf�li'uHillllRWH'.iIL'311BIHlV11P+1111R61YQl11ttllYll�' '�IHNdgIVllSiliY�lflhYliDtl <br /> i <br /> 1PPLICANT MUST PERFORM ILL WORK. 11 ICC09DINCI W[tH SAM JOIQUIM COUWTY ORDINANCES, Sf11E LAYS, AND RULES AMD CERTIFY OHS <br /> OF THE SIN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SICKITURE CEETIFIES THE FOLLOWING: '1 CERTIFY tHAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHILL NOT EMPLOY INN PERSON IN SUCH MINHER AS TO EECOM <br /> SUBJECT TO WORKER'S COMPENSATION LAWS Of CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGMIfURE CERTIFIES THE <br /> FOLLOYIIG: 'I CERTIFY THAT 11 THE PERFORMANCE OF THE WORE FOR WHICH THIS PZgMIT 1S ISSUED, [ SI[ALL EIIPGOY PERSONS SUOJEC <br /> TO WORKER'S COMPENSATION LIVS OF CILIFORIII. <br /> CALL FOR INSPECTIONS AT LEAST 43 110URS IN AE)VANCE <br /> OFFICE USE ONLY-44 23•y 011 12111 F •`•t ` ( yp <br /> Ny SSS SSSRSSSS S'IS'ISSSSSS\Sf SSSSSSSSS SSSS SSSSSSSSSSSSSSSSS SSSSSTSSS SSSSTiSSSSSY YSSSSSS^ISSSSS SSSVISS SSS YSS SSS SS+SSSSSSS'�SSSS JS <br /> SWEEPS I COMP I ILOC CODE DIST CODEI AMOUNT OURI AMOUNT RCVD C1IIfCASH ROD BY DIfE RCVD PERMIT I <br />