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ff <br /> ft- <br /> t t k tS k�tk t 'tT:til ti.kl:rtvt:v, k't}.n:an: <br /> JQIQIIIN .ft-ty HEALTH DISTRICTf. <br /> 0APPLICATION FOR PERMIT <br /> t. UNDERGROUND ThNX N, q <br /> 1601 E HIZELTON AYH., STOCKTON CAN; <br /> k: CLOSURE OR IBIHDONNENT N: telephone 12091 468-342D k �,R ) <br /> t�ffti:ft.ti:t -tva:t•r.t*111.ftftkl:kv.ty.tfi.11:kt:Nt'tv.tj:tytll aa:ti:n:a tv ff-ff ki: lP+l 4��RL3!1 <br /> APPLICATION FOR PERMAKEKTITEMPORIRT CLOSURE OR ABANDONMENT IM PLACE OF UNDERGROUND HAZARDOUS SUBStA � r�of.0jff"W <br /> THIS PERMIT EKPIRES 90 DAYS FROM THE IPPROVIL DATE. DO NOT WRITE IN ill SHADED BREIS. INDICATE PE MITI' ' LQWe <br /> of REMOVAL _____ TEMPORARY CLOSURE _ ABANDONMENT IN PLACE <br /> EPA SITE 1 L'/f 1� `yrs'/`�5 3Y PROJECT CONTACT I TELEPHONE 1 3 <br /> F FACILITY HANE �f� l-l- r✓�lIGE A (C�� PHONE I C �)133z3- 24S <br /> I <br /> C ADDRESS j-71 {✓JN P"'I-Te- <br /> I <br /> L CROSS STREET L-jLJ156 A\155 <br /> T OWNER/OPERATOR PHONE 1 <br /> C CONTRACTOR NINE <br /> PHONE I 9-3-1—bSG i <br /> 0 <br /> N CONTRICTOR ADDRESS f 1'J ' CI LIC I Z �€x'1Lc� CLASS <br /> Ib�vl - 3' AV i _ <br /> T T —_ WORK.COMP.1 <br /> R INSURER <br /> C FIRE DISTRICT MAaT Fig—r— �517T. PERMIT 11CNSPtR <br /> 0 LABORATORY NINE CA-&j <br /> d L S PRONE I (7_C>6) g�3'3-i 341 <br /> R SAMPLING FIRMA c> SAMPLING METROD �' ' e` OCV, <br /> kHIIYNJURIUlDH14llNI1GRIlpIN1gDBIIIfAtllllYliNVflHgC9BfDIIDYiNCYtlDM <br /> TANK ID I ?INK SIZE — CHEMICILS STORED CURRtMIL CHEMICALS STORED PREVIOUSL <br /> T _ _ <br /> I 39- _1�/ / ! C .6 SC:}i E 1 <br /> N 39-T f / , C�0 <br /> 39- <br /> !�� R LIST hDDIT IL TANK INFORMATION AS NEEDED ON SEPARITE FORA <br /> HNkYCIIHDHtI'NIktlNIIEUfiWDGIIVDIiDVD14WGDIIRNIBDINRRIIDDI1kREDl[. IINI!Ii11t111Ht1i1111HdIBIIIIIkiDDI' H!UIHBIIIIIBIDIL`HI1DI!fIDWEiiIIIIIIItIU�kJPI�lliltill!IY��:IfHlNlltI!111111nIItI�kCIIIUtII�IIIDIf�kB11111111UtII�IIDBIG1fHJlsllll@Illlll<lYllfHlll' i <br /> P APPROVED PPROYED WITH CChDITIONS __ DISAPPROVED <br /> L (SEE I'•4^ -:ITH COYDITIC]IS} —^_q, L °iJ re«1r <br /> A PLAN REVIEWERS NAME � ___� -- —____DATE_, <br /> N (� <br /> [IDI Id G ISI �#I�fIIR�DiYlll�lilllY6�6e9�I11UlBt �Ytd1 <br /> IPPLIChNT MUST PERFORM hLL WORK IN ACCORDANCE WITH SAM JOAQUIN COUNTY ORDINANCES, STITE LIWS, AND RULES IND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. CWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SOCH MANNER AS TO BECON <br /> SUBJECT TO YORKER'S COMPENSATION LIWS OF CILIFORN!A.' CijMTRACTOV S HIRING OR SUBCONTRACT[NG SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF TETE WOR[ FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORXER'S COMPENSATION LAWS OF CILIFORYII, <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED f -ofdtid=.��. ._�____ DATE .��� -__- <br /> OFFICB U g ONLY--BH 23 042/81 <br /> $$$$$$$$$ $$�$$$$$$$$$$$$$$ $$$$ $M$$$0$$$$$$$$SSS1$$$$$$$$S$$$$$$$$a$$$$$$$$$$$$$$$$$a$$$$$$$S$$$$$$$$$$$$$$$I$$$$ <br /> SWEEPS I COMP I LOC CODE D[ST CODE AMOU91 DUE AM{_,UNT RCYD CKIICASH RCVD BY 009 RCVD PERMIT I <br /> I <br />