Laserfiche WebLink
t APPLICATION FOR PERMIT t; SAN JOAQUIN�LOCAL e <br /> HEALTH DISTRICT <br /> N CLOSURE <br /> UNDERGROUND TANK 1601 E NAZELTON AVE., STOCK "y CA . co Pyg CLOSURE ABANDONMENTTelephone (209) 468-34W <br /> GG NN/�C� II ::?:?:?:::?'.0, Telephone <br /> Y:?:?:? r: ?:u:n: <br /> OAAL �ATTDNIP9R'PERMIMRNUTEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL _____ TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br /> EPA SITE 1 CA C 0 0 0 l $ c Liq PROJECT CONTACT f TELEPHONE t _ <br /> _ F- <br /> F FACILITY NAME <br /> A c . �Rn1 '� Q0 14,J lRQ _ �o15vp ei PHONE 11 U9- '023 -7-7LI ! <br /> C ADDRESS 1 0 1 1 Hwy l a o <br /> 1 �'YIAluT-CA . Cf4 . �I5336 <br /> L CROSS STREET AU S I (J <br /> I Vt k10 tq c-) <br /> T OWNER/OPERATOR <br /> yr PHONE 1 <br /> pA�vinl 1622 . STRICT _ ga3- 31 0 1 <br /> C CONTRACTOR NAME PHONE t <br /> O atfl-sZy 9tos3 <br /> N CONTRACTOR ADDRESS y3l �� O CA LIC <br /> T I CLASS <br /> R INSURER Y�t <br /> A .---- X115• WORK.COMP.t �`d C) It, <br /> C FIRE DISTRICT m <br /> T RtJ E %) C: T y PERMIT t/INSPTR <br /> nn JUN 2 19 <br /> 0 LABORATORY NAME v L( Wtq TE 4 ��� PHONE t <br /> R p L/O�THRJNn�iEviAL I;E <br /> SAMPLING FIRM*maliflimalimmmu *Llp' WA-Q69 Llg6 SAMPLING METHOD _ LiH <br /> T <br /> TANK 10 t TANK SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> A 39 _ • _ : 0000 GSL Q. LL_ t��L GAS <br /> _ 22ss <br /> N 39-- S 5 'b�--------- b o v L . ML L . &pk S. <br /> K 39 <br /> --------------------------- <br /> 39 <br /> --------------------------- <br /> 39 <br /> ----------------- <br /> Jim <br /> LIST AO TIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P V iuu�unnuuwuuuv• i •• i- i � . <br /> APPROVED <br /> _ PROVEO WITH CONDITION$ _ DISAPPROVED u <br /> L (SEE ATTACHMENT WITH CONDITI <br /> A PLAN REVIEWERS NAME __ _ <br /> N ------------------------- -----------DATE <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: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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, 1 SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSP CTIO S AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED �l�^, ,D q <br /> �------------------------------------------DATE__ - - <br /> OffTCE VSE ONIY -EN 23 O46 12/88 =___ <br /> fifffffifI COMPfiffifffffifffffffiffftfffffffifffffffffffiffifffffffffftififfiftfffffttfffffifififfffffffffffffffffffffff <br /> SWEEPS t COMP t LO CODE DIST CODE AND NT DUE AMOUNT R VD <br /> fb:h �Iulo;; r�n ga4 I f KC&! CASH RC D Y DATE RCVD PERMIT t <br /> i iav GtJ u <br />