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k t Lt tt k tt it kt kCt it L't kt Ct kt it tt kt aR.,it:It-'R:tt-It:kt APPLICATION FOR PERMIT ,: SAN JOAQUIN LOCAL HEALTH DISTRICT,: t: UNDERGROUND TANK t; 1601 B HAZELTON AVB., STOCKTON CA,: t: CLOSURE OR ABANDONMENT �: Telephone (109) 165-3120 k: k kt:011:1:111.,R:R:it-ktt*L':R.,ItLR:Rt,R:R R tl:t:r.M :R:Ittt:L't=It ff,I -R:ti:0: APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY THIS PERMIT BZPIRES 90 DAYS FROM APPROVAL DATE. DO NOT IRITE IN AIT SIRDID AREAS. INDICATE PERMIT TYPE BELOW: _ REMOVAL TEMPORARY CLOSURE -- ABANDONMENT IN PLACE I-- PA SITE I ✓� C C C' c^ /,3 1 C 9 PROJECT COPTIC! i TELEPHONE I 77 � FACILITY MAKE 'tet _ 7—,- ` PHONE I A �u i - e/ -7 C ADDRESS 6/ 1 w, 1 s a Vv w L CROSS STREET w y � R o , I —-- _ T OYNERAPERATOR PHONE ! f �! r Seo., .__ i C CONTRACTOR NAME U - d�' PHONE b �� ' � 0 I CONTRACTOR ADDRESS CA LLC I CLASS R INSURER V4 7;`:•,q WORK.COMP.I C FIRE DISTRICT _�,�, ;T-,c,,, PERMIT II/INSPTR r — 0 LABORATORY IAMBVTYX� r Cor '%VI P ft R PHONE I SAMPLING FIRMi tr �h SAMPLING METIOD bro -sS t ,�hr s-ec, Iddtl7!tlRIdIllliYliWddWIiGINNgIIdIIWNtlIIRRIIIIIdGJIIddIIWIiI�IYNdYI -__— _-_ _ c- u%.w / P/.— _ TAX[ ID I TANK slit CHEMICILS STORED CURRENTL CHEMICALS STORED PRIVIOUSL T / �' K 39- 39- 39-W -� LIST ADDITIONAL TANK IMFORHAriON AS NEEDED ON SEPARATE PORN �- INIdRGiIRd0di114RtlIIdIIIdNlNdIIldlddildUdllNYNNddddRNdINdNURlUd,dl !NilIIdIIdlligNlUdill#IIIdNlI�IIIIRdiRd!iIN:Eii!1111ik11lIJIdINIINddllllddld!JIdLNlilllllUIIIUJNN"ldl'litdld�IN�tlllidlllld�d?dllNuddlddlilNlJlRlllddidldltluldYNU1RIINlIIdRlillilNIIIIVLINIIiuYRfNdd'�' P APPROVED —APPROVED WITH CONDITIONS DISAPPROVED L -- A189 ATTACIINEIjr PITH COYDITIO I PLAN REVIEWERS NAN6 �'usz A ,DATE uI�NIdIdRud�+Wddum HillNININ�lRI YUWNNIII�IY�IIRdI�R111�duddlm�RY APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SIN JOAQUIN COUNTY ORDINANCES, SPATE LAYS, AND RULES AND REGULATIONS OF THE SAI JOAQUIN LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IM THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM SUBJECT TO YORKER'S COMPENSATION LAYS OF CALIFORNIA,' C04TRICTORIS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF TILE YORK FOR WHICH TIIIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC TO WORKER'S COMPENSATION LAWS OF CALIFORNIA, CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE SIGNEDCT,r�... -- l DATErt` 1 L_' OFFICE USB ONLY--SII 23446 I7-f81 -7-- $S$SS$$$S$S$S$SSS$$SSSSSS$$S$SSSS$$SS$S$S$$SSSSSSSSS$SSSSS$SSSSSSS$S$S$S$$$S$$SSS$$$$$$$SS$S$SSS$SSSSSSSS$SSSS$S$S$S9$S$S SWEEPS I COKP 1 LOC CODE DIST COOS' AMOUNT DUE AMOUNT RCVD CKIICASU RC9D BY DATE RCVD PERMIT !)