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.. ..ti... ,r^I�„�i,•.�:::,, rr^{,..:nwirt t,ith;;»»:.f1::»»:.{:,in <br /> APPLICATION FOR- <br /> PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` UNDERGOTANK 101 E IIAZELTON TOCKI -A <br /> CLOSURE ANDOh ENT K Tele hone (2051 AVE.,�4CO-53:1. <br /> K KK KKAKg iKN 1{ N II dl <br /> 11-9 H <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTAN+? 44RE SFA ITY <br /> THIS PERMIT EXPIRES 30 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. IND ICATFENP%BQ&TE4L�HEALTH <br /> I t PER4IIT/SERVICES <br /> X REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE 1 [A f> q 8/ 17 7 Sf PROJECT �,'ONTA�.i A TELEPHONE 9 G4U(r_ 6OLLI <br /> F FACILITY NAME - �i��1�.— �� �`Jii��{i'� PHONE <br /> A ,/ <br /> C ADDRESS q6-Z , rI L�J4N J,& I) <br /> L CROSS STREET <br /> ij - <br /> I <br /> T OWNER/eHIP TOT CGI- UGIL- GdLL�N PHONE i <br /> Y �✓ �>v 6.&L#OrloaI (114) <br /> C CONTRACTOR NAME �I�UIr CP1�1G� DN lNG PHONE I(-/� (s1tQj-19 90 <br /> a <br /> N CONTRACTOR ADDRESS P,01 P,70 t z1W } TUCAP9) CA.1-3276 CA LIC 1 A'i4q6,oj1 CLASS A <br /> T <br /> R INSURER. WORK.COMP.1 /�' �9 l� <br /> A <br /> C FIRE DISTRICT�6-�.-KroQ GIS 1%1j�_E 9,Er PERMIT t/INSPTR <br /> T <br /> O LABORATORY NAME at041 , jW6,jN(*g/4& -:9"V1c PHONE 1(��) 905- 1540 <br /> - 1340 <br /> R <br /> SAMPL I NG F I P.M' f-AM(_ AC7 Af6;vYF- SAMPLING METHOD` <br /> TANK ID I TANK SIZE ICHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSLY <br /> T000 <br /> L (. GAaLI N N f <br /> N s3-- .--- -2 ------ <br /> K 3- <br /> ------------ (d, 00 0 CA L-. y`` L ih�jUG I fi�I � 0 (30,6 <br /> - v---- ------------ <br /> 33- <br /> ---aaaaaaa__aaa_------- <br /> aa_rrra_aaaar___aaa_aa_a_aaa <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> �S .� 1 �!1 HYRl11{101+IQM M 1 { ,1 <br /> P APPROVED _APPROVED WITH CONDITIONS DISAPPROVED <br /> A PLAN REVIEWERS NAME ----- ✓ Gc� HMENT-KITH-CONDITIONS;______DATE_____ _ - �--------- <br /> N <br /> s <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAOIS,' AND-RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 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 BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 !`TOURS I N ADVANC=E -- <br /> ` r <br /> SI�' DATE �G ' <br /> GNED----*mL --� -L- -------- --L?/ =---------------------------- --------------- ----------- <br /> +OFFIGf VS <br /> f#ifffi#ff#i#Sfiit#iiifif##fifffiftIts SSii0ifiSiff#S#ifiif#fi##i#ifffififfiiifiiii##f#t#ffiSt3tiff#iiifff#Sftif#SfStt#Sif <br /> SUEEPE I ` COMP t LDC CODE 'DIST CODE' AMOUNT DUE = AMOUNT RCVD ' CK9/CASH RCVD BY DATE RCVD PERMIT 1 <br /> �T <br />