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k tX!t tk th CRr t�'tt kt tt ku tvam.tt.tva tv41,a atk.kt.Cy.tY tv tk.ff M.tt.t*ti:tt- <br /> t: APPLICATION FOR PERMIT k: SAN JOAQUIN LOCAL HEALTH DIWT w <br /> UNOERG0* TANK t: (601 E HAZELTON AVE., STOCK At: <br /> t: CLOSURE O BANDONMENT t: Telephone (209) 468 3420 C: <br /> .............oxo : : f: :t"xo :n:n:wwa:n:n:n:n:.r.x:::::u«x. <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 /> REMOVAL _____ TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br /> EPA SITE #— — ' PROJECT CONTACT 4 TELEPHON #—/✓C J `-e rc v 'ille-Ile <br /> SAG 000 1 S2 -36 S --- x.- <br /> # <br /> ` <br /> F FACILITY NAME L7/rJ S/Vr rs � � PHONE _`rte• c <br /> A — --- — <br /> C ADDRESS �p 1 ,s v. �'t° ✓""/'v S�`o�;' T-✓ <br /> I <br /> L CROSS STREET .A f�j,✓� 7u.✓ <br /> T OWNER/OPERATOR •f '��� 7 y c PHONE # <br /> Q vfor1_ <br /> C CONTRACTOR NAMEAIrJ77 eA,-' /tPc7e;t .SehN EL PHONE # <br /> N CONTRACTOR ADDRESSl, e�f e ��/�`� CA LIC # CLASS 1A10 <br /> T <br /> P. INSURER rcWORK.COMP.#A-'*1k/'G D y f�f3 <br /> A —�.� ------ <br /> C FIRE DISTRICT f''dfi✓� PERMIT #/INSPTR <br /> T —- --...-- — —— — <br /> 0 LABORATORY NAME PHONE # <br /> R -- -------- — -- <br /> SAMPLING FIRM* f'j'e SAMPLING METHOD <br /> mRMmmmflm@mmBpmmmmmlmRmmllm9Nl�ImmRIIIDRIR - — I --- <br /> TANK. ID # TANK SIZE CHEMICALS STOPED CURRENTLY CHEMICALS STORED PREVIOUSL <br /> A 39- <br /> N <br /> 9 - <br /> K 39 --- <br /> --------------------------- <br /> 39 -- <br /> ----------------------- --- <br /> 39 -- ..__....- -- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> flmmnmMmRRImmRRimlmllmRRIIIIRImRmlmflmflRmmRmMAmImR. flmRRmlllmmmlmRRflMmA mmmMmlllmmlllmllgmpml�fllllpmlmflmflmmlllRCBflMRpmRmmmlmERI�IIIRmGMmmflmOmmNmlmfllmiNlllNfllORlmmmRMBmRpNIIflflRNlNpmfl41!mill <br /> P _ APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L ( EE ACHMENT WIT CONDITIONS) g <br /> A PLAN REVIEWERS NAME ��__--------_-----DATE____ 2���fD <br /> N - - - - - ------ <br /> _—� Iflmlmmmmmmm�l!mmmmllmmnmmmmlmmnmamlmmmmmlllmmflmmmmmlmmmlmmmmmmmmmmfRmmNmmumRNmmmlRRmmllmlRmla!mRmmm!malmammlNmmmmnmmmRmmlX�mlmmmmRm�mmmoRmmmflammmm <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT <br /> 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br /> SUBJECT TO WORKER'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, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 IiOURS IN ADVANCE <br /> SIGNED '- -- - - - - - - - - - - - DATE---------------------------- <br /> OFFICE USE ONLY- EH 13 016 11/88 <br /> ffffffffffffffffffffiffffffffffSffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffftfffffffffffffffffffffffff <br /> SWEEPS f COMP # BLOC CODE JOIST CUDEI AMOUNT DUE I AMOUNT RCVDI CK#/CASH J_ RCVD BY I—DATE RCVO I PERMIT # <br />