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rt:Mtl:u:rkl:n#tv M:ti.tv kv'tv-t%:tv-tv tic tyn:t3ma tvtvtl ty-tv ROV,til <br /> APPLICITION FOR PERMIT SIN JOAQUIN LOCAL HEALTH DISTRICT <br /> I: <br /> UNDERGROUND TANK t: 1601 E HiZILTON AVB., STOCKTOI CAT: <br /> r. CLOSURE OR IBINDORKENT t: Telephone (209) 418-3420 t <br /> t:ty ti:LIX ki:ry tz R:W ff Liv.R:R:tv ti tim tv R:R:tl�All:tv ti:kv ti,R:ML kl:R:tir it ti:til .LTH <br /> APPLICATION FOR PIRMARZKY/TRMPORIRY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAILIDOUS SUBSTANCES STORAGE FACILITY <br /> 71115 PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN IIII SHADED ARRIS. INDICATE PRIKIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN FLICK <br /> — leFlq, <br /> EPA SITE.I PIOJBCTCONTICT & T 1�E P 1�c i6A e m l <br /> F FACILITY NAME PHONE 1 <br /> p )ae A <br /> A 4 <br /> C IDDRKSS <br /> I --- <br /> L CROSS STREET /y— <br /> I <br /> ? OWNER/OPERATOR PHONE I <br /> Irr o <br /> C CONTRICTOR NINE PHONE I <br /> 0 e- rid �tc Q. -9 6 9 - 9 3,1 - <br /> I CONTRACTOR IDDRRSSp.- U 066 V/524 CA LI( CLASS <br /> R INSURERVORK.COKP.I <br /> zz <br /> C FIRE DISTRICT y- \Z p Lj I/IKSPTR <br /> 0 LABORATORY KIM <br /> _ <br /> R )7 N/ ro h 0 <br /> SAMPLING FIRM' SAMPING METHOD <br /> hV/ t- <br /> TANK ID I TANK 3129 CHEMICALS STORED CURRENTLY CHIMICILS STORED PREVIOUSLI <br /> 000 r)lesp- <br /> Re5 <br /> 1 39- <br /> 19- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED 01 SEPARATE FORK <br /> P APPROVED _ APPROVED WITH CONDITIONS DISAPPROVED <br /> L (ii ITTACHKE!?!,YT CONDITIONS) <br /> A PLAN REVIRURS NAME <br /> K <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SIN JOIQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES IND REGULVIONS <br /> OF THE SIN JOAQUIN LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SICKITURR CERTIFIES THE FOLLOVING: 11 CERTIFY THAT <br /> IN THE PERFORMANCE Of THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH HINKER AS TO BECON <br /> SUBJECT TO WORKER'S COMPENSATION LIVS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY THAI IN INS PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT is ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LIVS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED ----DATR <br /> OFFICE USB ONLY--EH 23 046 12111 <br /> SSSSSSSSSFSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS-1 I COMP I LOC CODE IDIST CODRj _IKOUKT DUE I AMOUNT RCVD I CKI/CASH I RCYD 11 1 DATE RCVD I PERMIT I <br /> ............ <br />