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'i1'il'N'11'\9' <br />t; APPLICATION FOR PERMIT r: SAN JOAQUIN LOCAL HEALTH DISTRICT t: <br />♦ t; UNDERGROUN TANK' t: 1641 E HAPELTON AVE., STOCK.TO�, SJP// �� <br />CLOSURE OR 6DONMENT 1: Telephone (209) 468-3420 J P n � <br />l:naxn:n:naxiaa>:IxFa�:n:�r.il.i>aaaa:�a:��: ��ara?asa�a�: / <br />'APPLICATION FOR PERMANENT/TEMPORARY 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 I CAc000 203358 <br />PROJECT CONTACT k TELEPHONE I <br />F FACILITY NAME <br />C ADDRESS60 <br />6Lsl <br />�;-L CROSS STREET <br />-- -- — - <br />1; — --- <br />�t <br />T OWNER/OPERATOR <br />r. XN1 O_S _ <br />PHONE I <br />Y <br />93 _4/2 3 <br />------------ <br />C CONTRACTOR NAME 1 <br />S'Te e.; <br />PHONE I <br />--__ <br />O <br />N CONTRACTOR ADDRESSS-iO` U k- C" <br />,T -r.Q�� �2. ?6,AP6 <br />CA LIC I If y0 51 <br />7 <br />CLASS 1-0 yo <br />,. <br />R INSURER WORK.COMP.I <br />C FIRE DISTRICTPERMIT I/INSPTR <br />T0, —- ------ <br />1-'9100-6'13 - O <br />R LABORATORY NAME L4 PHONE I <br />T <br />t:> SAMPLING METHODSAMPLING FIRMt ato" Soil suw Pc( Tu BE 2 NuE ✓� <br />6.i 4` tA-A r -T— v a pass ru b <br />TANK ID I TANK, SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br />T. <br />A 1010 iese-L 2 <br />39-1f 1' -- <br />. --------------- _ <br />iM 39- ------------------- <br />.X` 39-1==-------------- - -- - <br />ri. <br />;Y 39--------------------------- <br />s. <br />i7p 39- --- --- - -- - - <br />M <br />LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br />P APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br />"A PLAN REVIEWERS f/ <br />NAME ISE ATTACHMENT WITH CONUlT1---- MOW <br />- <br />; APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br />i <br />,,VFTHE SAN-JOAAUIN-LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br />' <br />�SN;THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br />' <br />'SUBJECT TO YORKER'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 INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br />BI6NE0--- ---- - -- - DATE <br />'..OFFICE <br />8S£ ONLY --ER 1d Of6 11188 <br />ffSllffflSSlfffffffllSlfSffffffffflSfffIIllSffIIISISSfiffSffffffffffSlffffiffifffSiSfSftfffSffStlltfSfffSfSffffSSfllfftfS <br />SIIEE�PS,I COQ LOQ E DEQ AMOUNT DUE AMOUNT �CA�S�� ?(9y BY PERMIT I <br />