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v t I"!�-tit:tv L t'ff t t R:R:t V a::t I:L t:ft:R-tl:ff t V R'R tV R:R:R <br /> t1l: tl:tl:t:v t I jj��: <br /> APPLICATION WERMIT t: SAN JOAQUIN LOCAL HEALTH DISTRI.P <br /> UNDERGROUNU7ANK 1601 E HAZELTON AVE., STOCKTON <br /> CLOSURE OR ABANDONMENT t; Telephone (209) 468-3420 t: <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 /> -VXREMOVAL ----- TEMPORARY CLOSURE ---- ABANDONMENT IN PLACE <br /> PROJECT CONTACT k TE <br /> EPA SITE I C'4 e 17R <br /> _ 60() 1 �4 _/0 5, TELEPHONE <br /> r FACILITY NAME PHONE <br /> C ADDRESS '12,17 6-, <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE <br /> Y CzZ4 b 0 9,3 <br /> C CONTRACTOR NAME Es Rn� PHONE J;z 4/ <br /> 0 vica-, <br /> N CONTRACTOR ADDRESS 2 73 5 TeGP DRQ Sv ergCA LIC IV O's— CLASS 0 e16 <br /> I �S7-0 eJ�7-0 CA <br /> I INSURER WORK.COMP, <br /> A ......------------------- .............. <br /> -Iq <br /> C FIRE DISTRICT PERMIT I/INSPTR /Vrs01`45 sores UNVgQ rn"K W4�41!w <br /> A 1 W '.' lmo4z is T <br /> 0 LABORATORY NAME PHONE # 62 <br /> R )-710 /V1Fr/" 5 7- -0-,) 83e- 2-6-0 7 <br /> SAMPLING FIRM* SAMPLING METHOD <br /> TANK ID f TANK S12E CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSL' <br /> T <br /> A 39- Aa7cc77 --Lc <br /> D <br /> N <br /> K 33- <br /> 39---------------------------- <br /> --------- -- <br /> '39-------------------------- - <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> Emil <br /> P APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L c z� I, (�EEI�TICIIINI 11 1 CONDITIONS) <br /> A PLAN REVIEWERS NAME DATE <br /> N <br /> I= <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH GAN 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 /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOMf <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC1 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA, <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIG �;-f <br /> OFI <br /> � is <br /> SSSfffffSfftffffffffiffffSfffSfSifSffSSfffffffffffSfSfffESffffbSSfffffSfffSffbfSffSfffbfffiSffff <br /> M'P 11jOC CODE IDIOT NTCYT <br /> ffffffffiffiffbffffSffff <br /> SWEEPS I IC i jCODE1 AMOUN�DUE I J�Qog <br /> AMOU �U/CASH )Y �TE CYD <br /> PERMIT I <br />