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0 <br />t ti: ti'ti: till: it: it: ti: ti tit: 3. ti: ti: tiftit' R.ti: ti'ti: ti'ti' tt ti' ti: tl ti: ti' ti' ti ti- ti' <br />W IPPLIC1T101 FOR PERMIT W SAY JOIOUII LOCAL HEALTH DISTIICTC <br />t UNDERGROUND TAN[ t: 1601 E HIXELTOY AVE., STOCKTOYXCAC <br />t CLOSURE OR 1110DOIKENT t: leleploue (209) 168-3121 t <br />ttili It:ttti'ti ti:ti'ti tii'ffttti'ti- ti t11ti'titi'ti' ti till:ti'ti4i:114tti'tl:It: <br />APPLICATION FOR PERMANENT/TEMPORIRT CLOSURE OR ABANDONMENT 11 PLACE OF UNDERGROUND HIXARDOUS SUBSTIYCES STORAGE FACILITY <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DITB. DO NOT TRITE IN 111 SHADED AREAS. INDICITE PERMIT TYPE IELOW: <br />2REMOVAL —_ TEMPORARY CLOSURE — IBIYDONMENI 1N ?LICE <br />EPA SITE t C pia 24 b 8d 1 <br />qY s) 4& <br />PROJHCT CONTACT I TELEPHONE I <br />F <br />FACILITY NAME(T,, <br />L� { <br />PHONE <br />u <br />C <br />ADDRESS <br />JGQ <br />1 <br />F� �k) <br />L <br />I <br />CROSS STREET C 5/110 <br />T <br />OWNER/OPERATOR U't4A-t A. hLJA - AAornac� <br />PBORE I <br />I _C- • <br />I Z <br />� Z4'Cp1 <br />C <br />O <br />COYTICtOIYMEe� <br />rEN AU. <br />oS_ <br />PBOYB t <br />�-1 _Z%_7 -45(-o <br />COY181Ct0I dDDYBS97D s�NCl <br />LIC I89(Y .Z/,CLASS <br />T <br />R <br />1 <br />INSURER <br />S CtUaR�J <br />VOIK.COMP.I <br />C <br />FIRE DISTRICT SW PfE�GA�xcO <br />PERMIT I/(YSPTR <br />r;fE <br />1 <br />0 <br />LABORITOIT Y1ME < �etiw <br />PHONE Y4!�l <br />u�+ ( aS <br />R <br />SdXPLIYC V]RM' -��_ - SdXP61tlC NETYOD J�9�NIcSS <br />— <br />WICBIYYIWWONNtlWItWItam <br />?kit ID I G SIS CHEMICALS STORED CURREITLI CHEMICALS STORED PRIVIOUSL <br />T <br />1 _ <br />L, ZoGo <br />p -- <br />� <br />K <br />]9- <br />]9- – <br />— <br />LIST ADDITIOMIL TANK IMFORNITION IS NEEDED DY SEPARATE FORE <br />D'�WWYYRRDYlYYWIWYRDYGYBtlItldWWYWNNYpItlNWWWWDtl DN1YRYfWMYt0]ltll�trnyw[.g10_'WMII IIIN xx'IWXI^niNCY6 nYXx�tytl'iYi:flAniLliilttNtldGW9Y�tx�tD'YtlYOtlCY u <br />P <br />APPROVED _IPPROVED WITH CONDITIONS _ DISAPPROVED <br />L <br />ISEE1 I HMEYT YITN COHDITIOYS) <br />I <br />PLAN REVIEWERS RIME ,�� DITI <br />APPLICANT MUST PERFORM ILL YORK IN ACCORDANCE WITH SIN JOAQUIN COUNTY ORDINANCES, STATE LAYS, IND RULES IND REGULATIONS <br />OF <br />THE SIN JOAOUIN LOCAL HEIL1H DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br />11 <br />THE PERFORMANCE OF THE IDEA FOR WHICH THIS PERMIT IS ISSUED, I SHALL YOT EMPLOT ANY PERSON IN SUCH MANNER 1S TO BECOM <br />SUBJECT TO YORKER'S COMPENSATION LAYS OF CALIFORNIA.' CONTRICT021S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: 11 CERTIFY THAT IN THE PERFORMANCE OF TIIE YORK FOR WHICH THIS PERMIT 15 ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br />TO <br />YORKER'S LIPS OP CALIFORNIA. <br />CA[COMPEWSITIONn <br />'0 S E ONS AT LEAST 40 FIOURS IN ADVANCE <br />SIGNED DATE <br />OFFICE USB -•BTI 13 046112181 <br />SSSSSSSSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSis'SSSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSS <br />SWEEPS I COMP I LOC CODE DIST CODHI ►MOUNT DUET MOUNT RCVD CKI/CASH RCVD BY DATE RCVD PERMIT I <br />1 }"I Cay;. ��lo- vf-I i <br />I I I <br />