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t: APPLICATIOPPERMIT !; SAN JOAQUIN LOCAL HEALTH DIST <br /> k <br /> UNDERGRCWTANK !: 1601 E HAZELTON AVE., STOCY,TO n <br /> t: CLOSURE OR ABANDONMENT t; Telephone (209) 468-3420 t D <br /> .....??:......n:uaaar:u:n:�?:1r: <br /> APPLICATION FOD. PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES S ORAgE"F/W31L�lT�h fg89 <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL ____. TEMPORARY CLOSURE -__- ABANDONMENT IN PLACE - PL - )I <br /> EPA SITE 1 PROJECT CONTACT W TELEPHONE 1 <br /> — dOwo Qil�(Ps <br /> F FACILITY NAME ,N j�(� A(b �Nf (.k1ri0fj �(. Is)e+ , PHONE f p, / L — <br /> A _/Lf4 - Aga <br /> IADDRESS <br /> CROSS STREET <br /> T OWNER/OPERATOR d PHONE t <br /> YINr� R�TRTI �N�Ee.(JATor�A � Ir.�G . <br /> _ — 9L4 y - Sid i <br /> C CONTRACTOR NAME m _ PHONE 1 — <br /> D -- ao99 <br /> N CONTRACTOR ADDRESS C J 1 �NTO t��Q CA LIC t ( I 1� �J CLASSA � C <br /> R INSURER 00 l : WORK.COMP.1 ( I __I, <br /> A = -- - - � N FlLC <br /> C FIRE DISTRICT <br /> T PERMIT t/INSPTR <br /> , I <br /> R LABORATORY NAME PHONE t `J�a7- 4 <br /> 10500 <br /> SAMPLING FIRM! C' (1LIF, WATE+j LAf2s SAMPLING METHOD A7n04W !— <br /> TANK ID D TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSL <br /> T <br /> A 39- - �'��- �1------ Soo ISTD L L- <br /> N 39 <br /> --------------------------- <br /> K 39 -- <br /> 39 <br /> 29 <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P ---_ APPROVED APPROVED WITH CONDITIONS <br /> L --_- DISAPPROVED <br /> (S ATTACHMENT ITH CONDITIONS) G <br /> A PLAN REVIEWERS NAME ------ �� - DATE-_- "� - - <br /> N <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 1S 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, INSPE TIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED___ \ ( vw, _ <br /> --------- DATE_ -�_� <br /> OFFZCE BSE EY--EN 23 046 Z2/BB '"""'- <br /> fffitfifftffftffffSStffftffffSfffftSSffffffffftfffSffffffffttffSffffffffiffSftfffffifffififftffffffffffiftfffffifffffffff <br /> SWEEPS t I COMP 1 LOC CODE IDIST CODEJ AMOUNT DUE AMOUNT RCVD CKI/CASH I RCVD BY DATE RCVD I PERMIT 1 <br />