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tv ki:ki t- �V ff kl*ft til ti,Lt*t-t: ft Litt tl*ti:Lttnl*Lt ty tial.6-1�v kv 0 tv <br /> APPLICATION FOR PERMIT r SIR JOAQUIN LOCAL HEALTH DISTRICTt: <br /> UNDERGROUND TANK t: im 8 HIZRLTOM AVB., STOCKTON CAI: <br /> CLOSURE OR ABANDONMENT V. Telephone (205) 468-3420 L: <br /> t ki R:11 4,R:ft:It ti:LV L kit tt:t t:til:til:tv R:III:t:%:LIV R:R:R:V ti:ff ti:ti:kt til:ty ti:RI: <br /> IPPLICITION FOR PIRNANENT/TENPORIRY CLOSURE OR ABANDONMENT 11 PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORICE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DITR. DO NOT WRITE IN III SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> RBKOVAL TEMPORARY CLOSURE & ABANDONMENT IN PLICR <br /> EPA SITE I <br /> PROJECT CONTICT & TELEPHONE I <br /> F FICILITY MAKE T r PHONE I <br /> I --- f!C- PO,)M M rC'r-0 C-P,r- Tacj<, boz2vtno <br /> C ADDRESS 7 <br /> I <br /> L CROSS STREET <br /> I ---- Fat —c-PI ;tct <br /> ? OVNER/OPERITOR PHONE I <br /> T L I r-o—b-o-z---z-o-n o 6 r, <br /> C CONTRICTOR MAKE <br /> PHONE I <br /> I CONTRICTOR IDDRISS <br /> /0-1/1 5,� CA Lie 17.. 53 CLASS S <br /> R -INSURER 0( LC> C kA LictL WORLCOMP. <br /> C FIRE DISTRICT -,A3m-(5itu:,0 PERMIT I/INSPTR <br /> 7 <br /> 0 LIBORATORY RARE NIA 9 1 <br /> R ---- --..,--Lplll , <br /> SIMPLINO FIRM' UNLA SAMPLING METHOD <br /> ON MIA <br /> 11 f <br /> ------ <br /> TANK ID I TANK $119 CHEMICILS STORED CURRENTLI CHEMICALS STORED PRRVIOUSL' <br /> 139- <br /> 39- <br /> 39-- <br /> LIST ADDITIONAL TANK INFORKITION IS NEEDED ON SEPARATE FORK <br /> WIWWYWWWNWWIYWKWYWWDWKYWYXWWWWYWWWWYWOtl P APPROVED 7APEROVRD WITH CONDITIONS DISAPPROVED <br /> L <br /> A PLIN REVIEWERS HIKE 4Lt.:�(SRR ITTACMKEKT WITH CONDITIONS) DITZ <br /> mmwmu <br /> IPPLICANT MUST PERFORM ILL FORK IN ACCORDANCE WITH SAN JOIQUIN COUNTY ORDINANCES, STITE LIVS, AND RULES IND RECULITIONS <br /> OF THE 511 JOAOUII LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SICKATURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> 11 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED, I SHILL NOT EMPLOY INV PERSON IN SUCH MINMER AS TO BECOM <br /> SUBJECT TO YORKER'S COMPENSATION LIVS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY THAT IN THE PERFORKINCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJRV <br /> TO WORKER'S COMPENSATION LIVS OF CALIFORNIA. <br /> NCE 7 <br /> CALLLR INSP CTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNRD?'( , i? - 'y --v <br /> OFFICE USE OOY--Efl -23 0 <br /> SWEEPS I I COMP I I LOCCOD1 DIST CODEI AMOUNT DUB [ AMOUNT RCVD I CKI/CASH D B <br /> I RCVY DkT9 RCVD PERMIT I <br /> -j & <br />