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fftk}:k}:kot}:k}:t}tint: <br /> a APPLICATION FOR PERMIT k: $10 JOAQUIN LOCAL HEALTH UTSTRICTk: <br /> g UNDERGROUND TANK t: 1601 B HAZRLTOH AFB., STOCKTON Cit. <br /> t: CLOSURE OR ABINDONMBNT a Telephone (2091 468-3420 t: <br /> APPLICATION FOR PRRMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DITE. DO NOT WIITE IN 111 SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> — REMOVAL —_ TEMPORARY CLOSURE — IBINDONMENT IN PLACE 1 <br /> EPA SITE I CwC �Oa I��c�c� PROJECT CONTICT A TELEPHONE t <br /> F FACILITY NAME PRONE I aCga�_ 3 11 �� <br /> A <br /> C ADDRESS <br /> I of -- <br /> L CROSS STRBtT W'% 11 D U-) <br /> T OWNER/OPERITOR PHONE I <br /> 1 <br /> C CONTR/CTOR MAMB � O ��\_I CO x`11 PHONE <br /> O K� <br /> I CONTRACTOR ADDRESS p �, cl Ic, kM qN CA LIC I - CLASS <br /> R INSURER C c _ _1 �jS323 YORK.COMP.t q <br /> C FIRE DISTRICT PERMIT 1/IMSPTR <br /> T - <br /> & LABORA?ORYBAMBC0.� \�OC(1\C WC��QC �cti <br /> SAMPLING FIRMt SINPLING METHOD L <br /> - RBRPJYHIg01NkWIRIBBIRWIYRBIBININYNNBNNINRHNtl1ilYINRRN - - ----------- <br /> TANK ID I ?INK SIZE CHEMICILS STORED CURRENTLI CHEMICALS STORED PRBVIOUSL <br /> T <br /> tl 39- --- --- - <br /> K 39- <br /> - - LIST ADDITIONAL TANK INFORHATION AS HEED80 ON SEPARIT8 FOId <br /> WIWNYWIIIII'�IWYWRWWIIIINNWtlWWIIWItlIWBIIIIRRWI1WIWl. UBIMI!IYIIIVIIOIWRIIIgIIIIIIIIIBIIHIhtIIIJkBIIIIRIIi!IIIIUIINIWII01�BBkIWkIN!PIIWRIiIWBIgIYBBJYU19W116'iU!'IkIIkIINBIWYAwIkuIWIOBIIIRGWIIXIIIWIWBBIOtBWWIdIIIBWIiiNkNIIkBIIIBIWYRIWIW'� <br /> P APPROVED --APPROVED WITH CONDITIONS DISI ROVED <br /> L (SEB It CHMEN? WITH CONDITIONS) <br /> I PLIN REVIEWERS RAMS —_jam/ —_ <br /> N -- <br /> uWRwumR�RwRNHRN IMYNNN ROYWI WIINWRIRO <br /> APPLICANT MUST PERFORM ILL WORK IN ACCORDINCE WITH SAN JOAOUIN COUNTY ORDINANCES, STYE LAYS, AND RULES IND REGULATIONS <br /> OF THE SIN JOAOUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> II THE PERFORMINCR OF THE WORK FOR V91CH THIS PERMIT IS ISSUED, l SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER IS TO BECOM <br /> SUBJECT TO YORKER'S COMPSkSITION LIPS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT 11 THE PERFORMANCE OF TIIB YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO YORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED_ <br /> ----------------------------DAT E <br /> OFFICE USE ONLY--811 13 046 12/11 -- - <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS3SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS-I -COMP-I LOC CODE I DIST-CODE) -IMOUR? OUR �- AMOUNT RCVD CKI/CASA --RCYD BY^I- D1TE-RCVD-L PERMIT <br />