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-- AIR �) : Str; <br />M k�l1� t1'tY k1� t�1�t1' 01L11'tt� tti ti� k;:t1' C1'C1� t1� k1t1� t1�t1� L4' k1� t}k1� t1� �;; t1� k1� <br />IPPLICITION FOR PERMIT ► SAN JOAQUIN LOCAL HEALTH DISTRICTt:�ll�l1!'�11I <br />k: UNDERGROUND TANK t: 1601 E HAIELTON AVE., STOCKTON CA V77 6.1 `j )IVIy <br />t: CLOSURE OR IIINDORMBIT t: Telephone (209) 168-3120 <br />f41:1111' k11111l1� t1� t1 k11 k1 t1 k1 t1' C1 t111 kY t1 k1 t1' k1 t1't1 C1 t1 t1 t1 k1 ti: tt: t1; U 1_ 71989 <br />APPLICATION FOR PERMANENT/TEMPORIIY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HIIIIDOUS SUBS1I110ES STORAGE FICIL'�TY <br />THIS PERMIT EXPIRES 90 DAYS FROM�TN APPROVIL DATE. DO NOT WRITE IN 111 SHADED AREAS. INDICATE P961V TYPE' MOW:' <br />—✓ REMOVAL --_ TEMPORARY CLOSURE — A8I1DONMENT IN PLICS <br />K� <br />EPI SITS 1PROJECT <br />C % . <br />COITICT A TELEPHONE I <br />kEasy/----- <br />F <br />— — <br />FACILITY MAMBA` � � %cG6C�iN/CAL PHONE I <br />Ems/ <br />C <br />1 <br />ADDRESS <br />rJIC!! Afy-�STOC{C=i� liJ <br />L <br />CROSS STREET C/7//- EE % - <br />I <br />T <br />- <br />0111161/OPERATOR <br />- - - <br />PRONE I <br />C <br />0 <br />CONTRACTOR <br />PHONE 1 j <br />1 <br />CONTRICTOR ADDRESSS6g -'?,;�_C) <br />CA LIC 1309�Ui CLASS <br />T <br />1 <br />1--�- <br />INSUIBI <br />VORK.COXP.I SCJ <br />u <br />C <br />- - --=_------=_t ___------- <br />PIRG DISTRICT p PERMIT I/INSPTR <br />C, <br />J <br />0 <br />LABORATORY YAMS Z PHONE I <br />- — <br />SIMPLING FIRM C "F SIN [No METHOD <br />lxm <br />TANI ID I TIES SITE CHENICILSSif��RB�D CL'RRENTL CHEMICILS STORED PRKVIOUSL <br />N 39 -- ---- --- -- -- <br />— <br />LIST IDDITIONhL TANK INFORMATION AS NEEDED ON SEPARATE FORK <br />YYYHYYpNYBNYYW IYIYIIfYIYBNIIIIININNWIMC!YIDXIW11i!WNMIpIYNINIYYIIXWI"JYW!YIN6'WHWIXMIUYV9"JYI3iYIM'iYi!ITiWNIXUIXIINYUINoWNU6MNUGWIRIYWNNYY!XYXNYIIYIICWgiXlilflIIYNYWBYYIYWY;Ii <br />P _ APPROVED _ IPPROVBD WITH CONDITIONS __ DISAPPROVED <br />L (S997�TTACIIMINT WITH CONDITIONS) <br />1PLAN 197181IRS NAME <br />r C91 DATE <br />(% <br />Nummommi YNNYNMIYYIWMYYYtltlNYOYNMIW WYIYNNNWDNIHYNYR Y MANY <br />APPLICANT MUST PERFORM ILL WORK 11 ACCORDANCE WITH SAM JOAQUIN COUITY ORDINANCES, STITH LAWS, AND RULES IND REGULITIOMS <br />OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br />IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SMALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br />SUBJECT TO VORKER'S COMPBNSITION LIVS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF ?116 102I FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br />TO YORKER'S COMPENSATION LAYS OF CALIFORNIA. <br />CAL C-TI9-NS AT LEAST 40 HOURS IN ADVANCE <br />SIGNED_ �_-------_— ! ��. Es <br />1,----- ---- <br />---- -----DATE <br />OFFICE USE ONLY --III 23 016 12/81 <br />SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSis'SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br />SISEPS I COMP I ILOC CODE I-D3t CODEI (MOUNT DUB AMOUNT RCVD CKI/CASH I- RC90 BY I RCVD- I PERMIT <br />-DATE <br />-I <br />� <br />