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t: UNDERGk�u'n i^ aunuUin LULAL HEALTH DISTRICT / <br /> CLOSURE TANK t• 601 E HAZELTON AVE., STOCK <br /> t �,1DONMENT �' " { ; �, <br /> Telephone (209) '�' <br /> :�::�:?:n:►?�:?�:?�:::?:?:�?x;?::?:►s:�.:?�:?� 468-347u�./ �;;: <br /> . :?:::: ::::'::?:: ?:fir <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES 2 1989 <br /> THIS PERMIT EXPIRES 90 DAYS FRO THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PU ". <br /> UBSTANCES. St0 AGMIWICES <br /> CI <br /> Y • Pk� LLTX�ITH <br /> MOVAL li<i✓I1T <br /> - -- _____ TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE Jr gS _S C PROJECT CONTACT & TELEPHONE I {' a <br /> F FACILITY NAME 6 �0 / -3 7 �= <br /> A PHONE # _ <br /> C ADDRESS L(g �d ( SO U <br /> I K <br /> L CROSS STREET c <br /> I c,� -r�.� f�y`� <br /> T OWNER/((OPERATOR <br /> Y sly R yl_ C:7 PHONE a <br /> C CONTRACTOR NAME "_ <br /> 0 PHONE # <br /> a <br /> N CONTRACTOR ADDRESS L)3) � -sz4 4(D S-3 <br /> T 3� ��� �� m��-�� CA LIC 1 4gN(.D1--j CLASS <br /> R INSURER ��� <br /> A — �'nS_ WORK.COMP.# K� �O <br /> C FIRE DISTRICT 1 O(D <br /> T PERMIT #/INSPTR <br /> 0 LABORATORY NAME L.)F ��T�.O._ <br /> R �!�P> PHONE # 309 .- Lf 0 5o <br /> SAMPLING FIRMf QALIF . (�J(�T ��` L_.A� SAMPLING METHOD <br /> TANK ID I TANK SIZE <br /> T CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> A <br /> ----�-- - _. <br /> G A s <br /> N3 ------- ((A, <br /> O1Lam- <br /> K 39- <br /> ---------------------------------------------- <br /> ----- <br /> 39 39 <br /> ------------ <br /> 39Ginn <br /> llST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P � _ <br /> L ___ APPROVED ___APPROVED WITH CONDITIONS _ _ DISAPPROVED <br /> A PLAN REVIEWERS NAME ___ (S TTACHMENT WITH CONDITIONS) <br /> N - ------- -------- --------------------------DATE <br /> ----�oZ l �_ ------ <br /> APPLICANT MUST PERFORM ALL WORK !N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS,�AND�RULES AND REGULATIONS <br /> OF THE SAH JOADUIN 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 IS ISSUED, I 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 CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> C OR INSPE TION�S AT <br /> LEAST 48 HOURS IN ADVANCE <br /> SIGNED__ _ _ --�� - <br /> OfflCf USf OBtr--fH 13 0/b 11/88 ---------------- <br /> ---------------------------DATE _a 7 _ _------ <br /> ifffffffffffffffffffffffffffffffffiffftfffffftfffffffffffffffffffffftffffffftifftffffffffffffiffffffffffffftfitfiffffffff <br /> SWEEPS COMA� CODE GIST CODE AMOUNT OUE AMOUNT RCVD CK#/CASH RCVD 8Y DATE RCVD PERMIT f <br />