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F CLOSURE OR ABANpONMENI ► 16U1 E HAiELiON AVE., STOCKTON CAt <br /> Ft;:t3:ti'�N't;:tlNt�tCN�l�t:�ti�ti�t hOMe (109) 16@x,+yp <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN p "it;titt Nt; i f C!`ry <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT NPLWRITE ANY SHADED <br /> OF UNDERGROUND HAZARDOUS SUBST CE Si <br /> AREAS. INDICATE PERMIT TY FACILITY <br /> --- _ REMOVAL ___ 1EtWORARY CLOSURE BELDNI <br /> EPA SiTE t .--. ABANDONMENT IN PLACE <br /> -ACD002rj?577 PROJECT COBIICT Y TELEPHONE 1 <br /> F FACILITY NAME _ /3(-3R3� <br /> A O . <br /> ADDRESS <br /> 9�5 I PHONE 1 `131— <br /> L CROSS STREET ���� <br /> 1 l- WY 9p C <br /> i OWNER/OPERATOR _ <br /> PHONE 1 <br /> C CONTRACTOR NAME '13 <br /> 3n3Fs <br /> 0 _ S E M C 0 '" 1 <br /> N CONTRACTOR ADDRESS X2093 524-9653 <br /> i 431 W. 'Hatch IFd. Modesto CA LIC t <br /> R ENSURER 44,9864 CLASS A,B,C,Dl <br /> A Fairmont Insurance <br /> C FIRE DISTRICT WORK'C4W'1 R80558 <br /> T Grr 0 � S.goclti'q-�r PERMITI/INSPTR <br /> RLABORATORY NAME <br /> - <br /> SAMPLING FIRMS <br /> h-G' SAiWLIN6 METHOD <br /> T TANK 10 t TANK SIZE -7 'P t4c_ Q�-x ,pA 39- CHEMICALS STORED CURRENTL CYEIIICALS SiORED PREViOUSL <br /> -- - <br /> N 39-K 39-- 2pr 3 —�� t� ��£Gl <br /> 39- <br /> 39------------------------- <br /> P -- L. <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> -11 <br /> L APPROVED ... <br /> _APPROVED WITN CONDITIONS <br /> WEA PLAN REVIEWERS HANE __— DISAPPROVED u <br /> H i Y COND1ilONS) <br /> -------» <br /> APPLICANT MJOAQUINUST PERFORM ALL YORK IN ACCORDANCE yliH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS <br /> OF THE SAN PERFORMANCE <br /> LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING; <br /> RULES <br /> IN THE PERFORMANCE DF THE YORK FOR YHICN THIS PUED, AND RULES AND REGULATIONS <br /> SUBJECT i0 WORKER'S COMPENSATION LAYS OF CALIFOREN PERMIT <br /> H(RINGI SMALL TOEMPLOY ANY R SUBCONTRACTING <br /> SIN SUCH IGNATURE CNof NER CERTIFY <br /> STToBECO T <br /> FOLLOWING: '! CERTIFY THAT IN THE PERFORMANCE OF THE Na FOR WHICH THIS PERMIT IS ISSUED 1 �rI IE 10 RECON <br /> i0 WORKER'S COMPENSATION IN <br /> OF CAl1FORNIA. HE <br /> SHALL EMPLOY PERSONS SUBJEC <br /> CA ORINSPEC IONS <br /> AT LEAST 4a HOURS IN ADVANCE <br /> S1GNE0 _ <br /> 01FICE ➢S 04612/PO <br /> ...........«....»-.».........»...DATE.. —90 <br /> ftfiitfI 'COtftisfftfs{stfftifISt{ttltsttttsttttittitti{ittiiftittttitftistfitftisttftttttitfiftitsifitt:tftfftftttiftti <br /> SY E S t COMP t C CODE 0151 CODE AMOUNT DUE ..... •••»� <br /> AMOUNT RCVD CKt/CASN RCVD BY DATE RCVD PERMIT 1 <br />