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t lvtk tk t}:tkt}'r.:111ftkk t1411k�tk�t}'tk awt}:tk atk atk�tk-114t tkt> " ;:t}: <br /> t APPUNOERGRU�RTANKPERMIT r SAN JOAQUIN LOCAL HEALTH DI4T* <br /> • t: 1601 E HAIELTON AVE., STOCKTON CAt; <br /> t: CLOSURE OR ABANDONMENTt. Telephone (209) 468-3420 ORIGINAL D I <br /> n:nax narar rr:u:n:n�as:n:n:n:rs:n:n:n:n:rs:n:n:r�:raas:n:rsarn:raaaas: '` G i NA L <br /> t <br /> APPLICATION FOP. PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> (REMOVAL TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br /> EPA SITE t <br /> C1fJL-00000 -7'7 -7 PROJECT CONTACT f TELEPHONE t Torn o _ <br /> N£N 7 <br /> WARTE(� <br /> F FACILITY NAME 83--x- 3a3__FTa75 <br /> A HoGHn/ mF(,- IN C 1PNONE 1 <br /> I ADDRESS 19sa7 S . mClE� 1 Oq - �3_ g�3� <br /> SCA L.o \j <br /> L CROSS STREET ---- --- __ : AZ If' <br /> 1 ----_"---- <br /> T OWNER/OPERATORi <br /> _Y 1-7oGgi\) n1 PG . I I IV e PHONE i - --�- <br /> 2c� q - B3 �-73a3 <br /> C CONTRACTOR NAME <br /> O Seo <br /> PHONE — <br /> N CONTRACTOR ADDRESS ' �a I�b - <br /> T >z�j -� - CA LIC t yY9s(oy CLASS A, <br /> R INSURER _ <br /> A FtaY - WORK.COMP,t <br /> C FIRE DISTRICT _ <br /> T QUItC,p, � _ PERMITi/INSPTR — —"-- <br /> 0 LABORATORY NAME C/aL I F. <br /> R ��ar �A� PHONE 1 <br /> SAMPLING I"IRM* L �, WRT��C � SAMPLING METRO j" p i1 <br /> Y11 i +'V'J��EE hk <br /> TANK ID t TANK SIZE <br /> T CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> A 39- 1(� � vim? ' Ia opo GAt. <br /> N 39 JuLu <br /> - � ---��- 2 a o G4(AL vtv LCA <br /> N (! <br /> K 9- - <br /> ----- a I O� GEG . CSS N A <br /> EGULaR GFlS t ) -----__ <br /> 39- <br /> --------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P <br /> L ___- APPROVED ___ PROVED WITH CONDITIONS <br /> DISAPPROVED <br /> (SEE ATTACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME _ ��/�� <br /> N r�--------------------------------- -DATE -/ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIETHE <br /> FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSOS <br /> NS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALVR NSPE TIOS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED <br /> OFFICE 8SE ONLY--EN 13 016 12188-------- // <br /> -------------------------------------------------DATE_ (p- ( S-�cl <br /> fffifffffffffffffffffffftffffffffffffifffffffffffffffffftffffffffffifffffffffftfftfffftffffffffffftfffffftfffftffffffffff <br /> SWEEPS t COMP 1 LOC CODE DIST CODE AMOUNT DUE I AMOUNT RCVD CK1lCASN I RCVO BY DATE KCVO I PERMIT 1 <br />