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dile G� <br /> ' k�ti ki�kh�t 'tfi�ti�tti t2T�ti�kx�kt�tvkt�kir tt�kt�tt�t;:N�tt�tt�kt�ti'ti:t*III <br /> C4 kt�tk: <br /> r APPLIC Y POH PERMIT a SAN JOIOUIN LOCAL N T1ICTt: <br /> k: UNDERGROUND TANK k; 1601 E HAERLTOM AYR., STOCKTON CAk: <br /> k: CLOSURE OR 1111DOINSIIT k: TelepAoae (209) 160-7120 r <br /> APPLICATION FOR PRRMANRIT/TEMPORARY CLOSURE OR ABANDONMENT 11 PLACE OF UNDERGROUND HAZARDOUS SUBStINCRS STORAGE FACILITY <br /> THIS PERMIT HIPIRES 90 DAYS FROh THE IPPROVIL DATE. DO NOT 11116 IN 111 SHADED AREAS. INDICATE PERMIT TYPE IRLOY: <br /> V—/REMOVAL —_ TEMPORARY CLOSURE — ABANDONMENT IN PLACE <br /> EPA SIT: I PROJECT COITICT I TELEPHONE I r <br /> F PIctL[tr NINE �b � PdONB 1 9� <br /> I ��I <br /> C IDDRESS <br /> L CROSS STREET <br /> I - <br /> T OVNIR/OPERATOR PHONE 1 <br /> C COYT11CtOR NINE �- <br /> 0 <br /> I COITRICTOR IDDRESS �� CA LIC 13 LI Y 3 CLISS <br /> I INSURER <br /> WORK.CORP.I� <br /> C PIR: DISTNICTT PERMIT I/IYSPTR <br /> 0 LABORIT0IY tl1M8 PROVE 1 S yOSC� <br /> `f.%�9 <br /> SIMPLIYG FIRM' _ SAMPLING <br /> — WgkNYNN00WI0NMW _ <br /> TANI ID 1 TINK SIZE CHEMICILS STORED CURRENT6 CHEMICILS STORED PREVIOUSL <br /> N 79- — <br /> 131- <br /> LIST <br /> ADDITIONAL TINK INFORMITION AS NEEDED ON SEPARITR POIN <br /> IPP90VID 1PPROVBD WITH CONDITIONS __ DISAPPROVED <br /> 1TTACNMEtlf WITH CONDITIOYSI <br /> 18Y[EYHRS N1ME � D1fE —�� <br /> YBYWYI <br /> IPPLICANT MUST PERFORM ALL YORK 11 ACCOIDANC¢ WITH SAN JOIOUIN COUNTY ORDININCES, ST11R LIVS, AND RULES IND REGULITIONS <br /> OF THE SAY JOAOUIN LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SIGKITURI CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER 13 TO DECOR <br /> SUBJECT TO YORKER'S COMPENSITION LIVS OF CILIFORNII.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGN/TURK CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY TH1T IN THE PERPORMINC¢ OF THE YORK FOR WITCH THIS PERMIT 13 ISSUED, I SHILL EMPLOY PERSONS SUBJBC <br /> TO YORKER'S COMPENSATION LIVS OF CILIFORYII. <br /> CALL ['0 S IONS AT LEAST 40 [[OURS IN ADVANCE, <br /> SIGNED_ 3/i; <br /> OFPI 8 BN 23 016 12/11 T <br /> SSSSS SSS, SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS I CORP I- LOC CODE I DIST CODRAMOUNT DUBJj , CK AMOOWT�CVD �- CASE I RCTD-RY^I—DItB RCVD_ I PERMIT I <br /> it161 /d PL> C7 / 3;� 3 <br />