Laserfiche WebLink
G It 11'tX kl:11 1 tt1 1:11 tit aa:ti:lK tt'tt:l3itt:ff ff tkt2:ti'li:tE'l2 t'!'It tt�11 t{:!}: <br /> t: APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT *109 <br /> K UNDERGROUND w 1601 E HAZELTON AVE., STOCKTON Ci j L <br /> t: CLOSURE OR AB uUNMENT t: Telephone (209) 468-3420 r / y' <br /> ttttit':aa::::::t:'t:rtxlra�tYt: Y::::a:'.'t'.L$:n:?rr:$::::t';:�:::�'Ix DT ��'1 19�' �,� <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUB$TANCES STORAGE'FACILITy-,)0 <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE'BELOW; <br /> REMOVAL _____ TEMPORARY CLOSURE -___ ABANDONMENT IN PLACE <br /> EPA SIT[ 1 Cft C C)00 0 S 3 PROJECT CONTACT 1 TELEPHONE I �o N rJ PHILIPS —�J'I�_SBk <br /> F FACILITY NAME �N (�(��r(�(f, IN(fiQJlF1fI0�JRl. ltJC • PHONE t <br /> A 944 - Sga I <br /> I ADDRESS $a 5- NAVL{ ORI& STT) CKT-0 ONL IF �15a o 6 <br /> L CROSS STREET <br /> I d �T <br /> T OWNER/OPERATOR PHONE t <br /> Y INpjR TATS- IWR4, NATIQOp� l- IT4G - _ q4y - 516a i <br /> C CONTRACTOR NAMEe c,YA CA PHONE 1 a o 9-sa Li - 9 653 —` <br /> O c) <br /> N CGNTRACTOR ADDRESS L�31 W �p<Teq CA LIC 14yj :6`1 CLASS V C61 <br /> R INSURER WORK.COMP,1 ON PI LC <br /> A <br /> C FIRE DISTRICT C�� PERMIT 1/INSPTR <br /> T <br /> 0 LABORATORY NAME l l WATzR Labs EMETHOD <br /> !R7_ (. v iJ^' ,o <br /> R <br /> SAMPLING FIRMi CALIF . WATtP, LAjb5 SAMPLI <br /> TANK ID 1 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSL <br /> A 39 - ?C 3�' — OI �J <br /> -- - 0 O l l4 T f �J L <br /> N 39- <br /> --------------------------- <br /> K 39 <br /> --------------------------- <br /> 39 <br /> --------------------------- <br /> 39 <br /> --------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P ____ APPROVED -_ APPROVED WITH CONDITIONS _ DISAPPROVED <br /> L (SEE ATT HMENT WITH CONDITIONS) y <br /> N PLAN REVIEWERS NAME -------------------- DATE- DATE - J <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 /> CAL FOR IN8PE TIONS AT LEAST 4E1 HOURS IN ADVANCE <br /> SIGNED___ <br /> - -3-- --- ----------------------------------------DATE_ -------- <br /> OFF FCE USE LY--EN 23 Old 12/BB -------- <br /> sssssss►sssssssssssssssssssssssscssssssssssssssssssssssssssssssss»sssssssasssssssssssssssssssssssssssssssssssssssssssss <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CKI/CASH RCVD BY DATE RCVD I PERMIT 1 <br />