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n:tv m:ki:t I:ki:till:tnl:a a ft ki:t V ti: tv tv <br /> k: APPLICt FOR PERMIT k: SAN JOAQUIN LOCAL HEALTH,.,, ICT <br /> r. % i �.- <br /> k: UNDOMOUND TANK 1601 E HAZELTON AVE,, STOCK-wN CA <br /> CLOSURE OR ABANDONMENT t: Telephone (209) 460-3420 <br /> ti: 03,0 3. 3.:, :, : >: C <br /> .31.31....:.>..:..:.3. <br /> I'll:ter::11Y OX 03,:Py. <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM <br /> HE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> /REMOVAL ..... TEMPORARY CLOSURE .... ABANDONMENT IN PLACE <br /> EPA SITE I GSL, O <br /> lea 4/ PROJECT CONTACT t TELEPHONE I <br /> DL- <br /> F FACILITY NAME E # <br /> leo <br /> A J-)P-�e -u-tF PHONE # <br /> 8 2- 3 S.27(0 <br /> C ADDRESS <br /> 1 2-GO S - H Aj ti A A <br /> L L CROSS STREET <br /> I <br /> T OWNER/OPERATOR Au 10 PHONE I <br /> I <br /> I <br /> CROSS <br /> STREET <br /> T OWNER OPERATOR <br /> Y <br /> A (4 t <br /> NT M <br /> C CONTRACTOR NAME PHONE I <br /> 0 011 <br /> T R D L <br /> Z- 451 <br /> N CONTRACTOR ADDRESS <br /> T CA LIC I CLASS <br /> 5 <br /> T 7�7.ct <br /> R INSURER 41 A <br /> A WORK.COKP.1 <br /> C FIRE DISTRICT <br /> T PPERMIT I/INSPTR <br /> (zp- Deo� <br /> 0 LABORATORY NAME PHONE # <br /> R 13 qc) <br /> SAMPLING FIRM# SAMPLING METHOD <br /> T TANK ID # CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSO <br /> A 39-____,23 4e <br /> N 39 <br /> K 39- <br /> 39 <br /> 39- ------------------------- <br /> LIST <br /> 9- ------------------------- LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P <br /> L APPR VED ---APPROVED WITH CONDITIONS ---- DISAPPROVED <br /> k (SEE A? ACHMENT CONDITIONS) <br /> AN REVIEWERS NAME ..r <br /> - ----------------------DATE__ -2 <br /> N ------------ <br /> ----------------------------- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN 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 IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: Of CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECI <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE' <br /> SIGNED <br /> 0FFicFU-S-E--0-N,-tY----,-EH---23-0--j6---/2188-------------------------------------------------------------DATE <br /> ------------------ <br /> ffffitffiftiffiffffftttfiftifffffftffffftfftfff <br /> SWEEPS COMP I ILOC CCE DIST DE AMOUNT DUE I AMOUNT RCVD K CASH RCVD By <br /> # <br /> I I I DATE-RCYO I PERMIT I <br />