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r.ft.ff.zt 0.ti-,tl�tvtit ft ti:41:tv ft tt tt tv tv a rr.t:r.ti:ft.11:R%n --ti.tt.tt. <br /> appLICITIOV FOR PERMIT y SIX JOAQUIN LOCAL HEALTH DISTRICT,: <br /> UNDERGROUND TINE HAllLION 179., S?OCX101 CA,: 1 <br /> g: CLOSURE OR ISISMiXEIT Telephone (2011 468-3423 <br /> t.ff ft ti:ft ff.Ift:ff tt:ti:ttf ti:R:ft k1l, ti:ft ti.,ti:ft ti:R:ft L.I.,R:R:ft:R:ft [N\'1F&)f4MENTAL HEALTH <br /> IPPLICAflog FOR PERMAN9NI/TEMPORIRT CLOSURI OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBS?IyCZS1'R2TR WKS'l,- <br /> THIS PERMIT RIPIRES 30 DAYS FROM THE APPROVAL DITE. DO NOT 11178 19 111 SHADID AREAS. INDICATE PERMIT TYPE 19LOW: <br /> ✓ REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLICI <br /> IPA SITE I C <br /> 000 Z 10 7,5 3 PROJECT CONTACT i TELEPHONE I LL- <br /> 'T <br /> F FACILITY NAME 1N, n ( CCN-m I tj ma Co ellc(ZA-71 PHONE 1 1 IS-7 I <br /> I A , <br /> C ADDRESS -400 Nq GST VAI-Pt C-0 f•OAD 'Tp-t%cy _c- IT 53-7(p <br /> I — <br /> L CROSS SIRII? <br /> I - <br /> ? OVNER/OPERITORZ©9 <br /> 1 "Z14LAIIJO C04'rA149Z P—10 P re-A 1-1 c) __t <br /> C CONTRACTOR MINEA LT- PHONE 1 <br /> I CGITIIC?OR ADDRESS PL5;(6 L–AN1 C1 Uc I 6273(A CLASS -b, rcpt <br /> ? 5 (0 9 t <br /> I INSURER -i::,,C-K c--T-r� f VORL COMP I c,S i 1c) <br /> C FIRE DISTRICT PERMIT I/Imsm <br /> I T c--r 7 Evocwch, Amu& <br /> 0 LABORATORY MIME AG(lie, 12t4 v i ieo-J P1 ENTIA L-- PHONE I <br /> SAMPLING FIRM' SAMPLING METIOD HA-t> <br /> TANK 10 1T,yx SI:z CHEMICALS STORED CURRWO CHEMICALS STORED PRVIIOUSLI <br /> 14 10< 1 6 <br /> LC30 5 <br /> 31- <br /> LIST ADDITfOMIL fAXX INFORHITIOX AS NE-POYD 09 SEPARITZ F0211 <br /> P IPP20V2[) IPPRO720 WITH C1v1:;DIqj1cxS D[SAP?3079D <br /> L -,(SEE ITTICum 91 rTH C0901TICIS) <br /> 11 PLAN 199IEVERS MINE <br /> Z D A 12 <br /> RAWmum wwmAmm <br /> APPLICANT MUST PERFORM ILL WORK 11 ACCORDINCE WITH Sig JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES IND REGULATIONS <br /> OF THE 311 JOAQUIN LOCAL REALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOfINC: 11 CERTIFY THAT <br /> IN ?89 PFRFORXANC9 OF THE VORX FOR VUIC4 THIS PERMIT IS ISSUED, I SHALL 10? EMPLOY ANY PERSOI IN SUCH MANNER 13 TO BECOX� <br /> SUBJECT TO WORKER'S COMPENSITICM LAWS OF CILIFORVIX.1 CONTRACTOR'S 9IR[9C OR SUBCONTRACTING S:CXj7UR9 CERTIFIES THE <br /> FOLLOVINC: 11 CEiTIFY THAT IN THE PE2FORMANCE OF THE Voki Fai WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SL'BJZV <br /> TO WORKER'S COMPENSATION LAYS OF CILIFORY11. <br /> CALL POR INSPECTIONS AT LEAST 40 11OURS 114 ADVANCE <br /> 4- <br /> SIGNED– DATE <br /> OFFICE USE CHLY-411 12111 <br /> Sv3EPS I CORP "07 co" I'll COOS E[ AMOUNT RC70 <br /> OUNT DVS _CNIC159 RCYD 31 DITE RCVD PERMIT I <br />