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IPPLICITION FOR PERMIT $IN JOAQUIN LOCAL HEALTH DISTRICTv RECEIV <br /> UNDERGROUND ?AN( 1601 E HIZELTON AVE., STOCKTON Civ G ED <br /> CLOSURE OR IIINDOMMBIT Telephone (2011 468-)420 NOV 10 1989 <br /> ENVIRONMENTAL HEALTH <br /> IppLICITION FOR PERMANEKT/TEXPORIRT CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HIZIRDOUS SUBST14i R MflGi Afta ES <br /> THIS PERMIT EXPIRES 10 DAYS FROM THE APPROVAL DATE. DO NOT VII?R IN III SlihDZU AREAS. INDICATE PERMIT TYPE IELOV: <br /> REMOVAL TEMPORARY CLOSURE -- ABANDONMENT IN PLICS <br /> ----PROJECT T <br /> EPA SITE I CT CONTICT & TELEPHONE I L2u` <br /> F FACILITY NAME0 0 PHONE I �-Ct <br /> C ADDRESS • e c fc- <br /> L CROSS STRAIT <br /> OINER/OPIRITOR PUONE I <br /> F--Z STAR J <br /> F- O424Cktj OA(Z�Cf-0-y-, --; I <br /> PHONE I <br /> ------------ <br /> CA LIC I CLIss <br /> CON"'CTOR 1OD"SS \-2-3-L (L ArJ C T- - <br /> -- <br /> R INSURER VORK-COKP-1 <br /> C FIRI DISTRICT �AA,'JNUA (:1 AWT PERMIT I/IMSPTR <br /> I — <br /> 0 LIBORItORY NINE p, jj 0 tj I PHONE I <br /> I <br /> SAMPLING FIRM$ SIMP ING METHOD <br /> OmODDYmmUWOYmYNmWtlImImIUYIWII00mmYlYllimliIUARl <br /> TINK ID I TIKK SIIE CHEHICLLS STORED CUIRREXTO CHEMICALS STORED PRIVIOUSL <br /> —194-11, <br /> 39- <br /> 31- <br /> -- <br /> cy-lc-) <br /> �c);-- <br /> cy- c <br /> LIST ADDITIONAL fAXK INFORMATION AS NEEDED 01 SEPARATE FORM <br /> P "NOAPPROVED --IPPROVID WITH CONDITIONS DISAPPROVED <br /> L (SEB ITThCHMEN? WITH C04DITIC931 DATE <br /> I PLIN 19111VIRS NINE <br /> I <br /> IPPLICANT ffl? PERFORM ILL RORK IN ACCORDANCE WITH SAN JOIQQIN COUNTY ORDINANCES, STItR LITS, AND RULES IND REGULITIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE YORK FOR VRICH THIS PERMIT 19 ISSUED, I S41LL ROT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECON <br /> suaiEcy TO YORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCOXTRACTINC SIGNATURE CERTIFIES THE <br /> FOLLOWING: al CERTIFY ?HIT 11 THE PERFORMANCE OF THE PORI FOR WHICH THIS pgqxlt 15 ISSUED, I SMALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S CONPENSITIOK LITS OF CILIFORIII. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED_ <br /> OFFICE U <br /> SWEEPS 1 AMOUNT DUE] AMOUNT RCVO CKI/CAS1I BY 0119 RCVD_j PERMIT I <br />