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t kfi t kt ti it:Fr.3:tit tZ t�`ti kt tt tt°t t�!tt tt It:ti:R:I:r for ti tt tt kk tt ) ,Cr <br /> r IPP 67101 FOR PERMIT w SAN JOIQUIM LOCIL HEALTH DISTRIC%: <br /> k UIDERGROUND TANK R: 1601 E HIZELTOM AVB., STOCKTON CAt: <br /> t: CLOSURE OR 1111UONNEIT t: Telephone (204) 468-3420 t: <br /> C tt <br /> it:it'ttm tt:it:tt it'it tit.'it: ki ti tl'ti ti ti ti tt ti t{.it:tV ti ti ti.R:R it:it:it: <br /> APPLICATION FOR PIRMANENT/TEMPORARY CLOSURE OR 181IDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT RYPIRES 40 DAYS FROM THE 1PPROVIL DATE. DO NOT WRITE IN III S11011 AREAS. INDICATE PERMIT TYPE IRLON: <br /> REMOVAL —_ _ TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> ..�rS,� �r St. PROJECT CONTACT S TELEPHONE 1 <br /> BPA sITI 1 ev aag7"F r1� L-1 I d <br /> F FICILITr MIMI -- PHONE I <br /> I s's� N. Satc.r+�-w� S"*. o <br /> C IaaRESS S0.G ra-wl a S t <br /> 1 — <br /> L CROSS STRAIT �Q J`e �a r c� '-I-- <br /> 1 _ <br /> T OINB OP@11T01 PHONE 1 �- <br /> C CONTRACTOR AIME - PHONE 1 <br /> I CONTRACTOR IDDRISS CA LIC 1CLASS <br /> T a CL <br /> S1�8/�' 131 <br /> iISU@R1 �,� N+ .��,� - - WORK.COMP.I <br /> I _ 7-i re r1h a r r n _ �— - 3 W �S3 j ri 1 '3S F <br /> C FIRE DISTRICT 0 d" PERMIT I/INSPTR _. <br /> 0 LIBORITORY MimiI PHONE I <br /> Oki me-,n.�« � �� - % 93 - 1.310 <br /> SAMPLING FIRM, `.< SAMPLING METIOD <br /> i1r'kef� 1" r) A e r <br /> TINT IO 1 TIK1 SIZE CHEMICALS STORED CL'RRENTL CHEMICALS STORED PRBVIOUSL <br /> If— <br /> LIST 1DDITIONdL TINK INFORMATION AS NEEDED OM SBPARITE FORM <br /> �I�'I,IX111111 4W w wNIIHr'Its'I"NH��utiRNNNNYlML'YIHdu�uwAuuiuuiiMituiii�um <br /> P APPROVED _ IPPROVED WITH CONDITIONS _ DISAPPROVED <br /> L (SEB ATTACHNBMT WITH CONDITIONS) <br /> i.r <br /> l PLAN RIV[ENE13 MIME DATE �/ Z ---I <br /> APPLICANT MUST PEIFORN ILL WORK II ACCOROJACE WITM SIN J04OUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND RRGULITIONS <br /> OF THE $19 JOAOUIN LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SIGIITURB CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERPORNAMCB OF Tlls WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL MOT EMPLOI IVY PERSON IN SUCH MINMER IS TO BECOM <br /> SUBJECT TO YORIBR'S COMPENSATION LIWS OF CALIFORNIA,' CONTRACTOR'S HIRING 09 SUBCONTRACTING SIGNITUIE CEITIFI$S THB <br /> FOLLOVIIG: 'I CEITIFY THAT IM THE PBRFORNINCB OF till WORK FOR YBICN THIS PERMIT 13 ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO 1011911 COMPENSATION L11S OF CILIF011I1, <br /> CALL FOR INSPEC IONS AT LEAST 911 IIOUIZS IN ADVANCE <br /> SIGNEDDATE '- 1 9 <br /> OFFICI b8—ONLY-SH 21 016 ! / �— <br /> ##SSS$S#SSSS#SSS##SSSS#S##SSSSSS##SSSSSS###S##SSS##SSSSSSSSSSSSSSS#SSSSSSSSSSSSSSSSSSSSSSSSSS#SSSSSSSSSSSSSSSSSSSS#SS#SSS <br /> SWBRPS 1COMP I LOC CODE DIST CODE' AMOUNT DURI AMOUNT RCVD CKI/CASH RCVD BY DATE RCVD PERMIT 1 <br />