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tlxlt,It:It.1:1., t'1'�ttM.1:LIt:It vft.I'rL4.It:It:R:Iitt-lt.%Ikv. .,a.Ik'CL&3: <br /> c APPLICATION FOR PERMIT a: SAN JOIOUIB LOCAL HEALTH DISTRICTI: <br /> UNDERGROUND TANK N: 1601 E NIZELTON AFB., STOCKTON CAN: <br /> I: CLOSURE OR 181NDONMEIT N: Telephone (209) 061-3120 E <br /> GI1:I1wffN:IT1:111IyIt Itt1:14111:1:Its Ix It�tt�et It�It�tt It It� <br /> APPLICATION FOR PERMANENT/TEMPORIRT CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DITH. DO NOT IIITE IN 111 SIIADBD AREAS. INDICATE PERMIT TYPE BELOW: <br /> ---_ EMOVAL TEMPORARY CLOSURE _ABANDONMENT IN PLICI ---- <br /> BPA SITE I IcgC, 00O) 013— PROJECT CONTICT A TELEPHONE I <br /> F FACILITY NAME <br /> C IDDRESS <br /> I — <br /> L CROSS STREET <br /> OWNER/OPERATOR PHONE Ij� <br /> ICONTR/CTOR NAME �, PRONE 1 <br /> I CONTRICTOR IDDRRSS K1 CA LIC I CLASS <br /> INSURER VORK.COMPA A <br /> C FIRE DISTRICT � ` PERMIT I/ItlSPTR <br /> T -- <br /> 0 LABORATORY NINE C - Lafk PHONE I <br /> R <br /> SAMPLING FIRM' t✓4.t° A-U✓ — SIMPLING NETNOD �4� � 1Y <br /> NDWPANRNNNIWNNDNNNNINNDNqm ,:� <br /> — -- — — -- <br /> TANKTIKK 812E p CHEMICILS STORED CURRENTLYCHEMICALS STORED PRIVIOUSL <br /> 1 39- — <br /> 39-� <br /> LIST IDDIT[OVAL LINK INFORMATION 1S NEEDED 01 SEPARATE FORK <br /> P PROVED APPROVED WITH CONDITIONS ___ DISAPPROVED <br /> L J I �� BB /t CI ENt WITH COHDITICYSI <br /> I PLAN REVIEWERS NIMB �L" DATE <br /> Y <br /> NWNNONtl�q�NWYNNNNNNYNUNINRgRp�WYIWIRNRYNKNRNIRN <br /> APPLICANT MUST PERFORM ILL WORK 11 ACCORDANCE WITH SIN JOIOUIN COUNTY ORDINANCES, STITH LAYS, AND RULES IND REGULITIOHS <br /> OF THE SAN JOAOUIN LOCAL HRILTH DISTRICT. OWNER OR LICENSED AGENT'S SIGXITURB CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHILL XOT EMPLOY ANY PERSON IN SUCH MANNER 13 TO BECOM <br /> SUBJECT TO YORKER'S COMPENSITION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY THAT IN THE PERFORMINCE OF TIIE 1011 FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S CONPENSITION III$ OF CILIFORIII. <br /> CALL FOR INSPECTIONS AT LEAST 40 YIOURS IN ADVANCE <br /> SIGNED DATE__--_____ <br /> OFFICR USE OHLY-411 23 016 12/11 <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS$SSSSSS$SSSSSSSSSS5SSSSSSSSSSSSSSSSS <br /> SWAPS I COMP I LOC CSE JOIST DUE AMOUNT RCVO ^I CKI/CASE- RCYD BY I ID/�t �9 I PERMIT I <br /> � �-_ __, a �J IL— L jl / of 1 <br />