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TRICT <br /> t; APFLICATION' FOR PERMIT t . SAN JOAQUIN LOCAL HEALTH DISt; <br /> ., <br /> r UNDER �1 TANK t: 1601 E HAMILTON AVE., STOCK :A t: <br /> CLOSUREABANDONMENT t: Telephone (2091 968-392 t: D c Ea i <br />-F M1 �'��������,���}�i iii•ii��'�i'y i�i��i Yew�•F+-ii"i'iii•ii"ix�iiii?w�-�}-�i•aii'iii'•�M-��f? 5 ' <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCMIRAG©FIB <br /> OY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE'. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> ENViRONIVICNTAL IEALTFI <br /> f .:;. <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE pERM1TISERVICES <br />' EPA SITE t ED <br /> ECTCONTACT i TELEPHONE I <br /> C� / �P.r c� <br /> F FACILITY NAME 1 ]KNEST�t0 cfl L G G 2'r2 q 9yB <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I6 E T- <br /> T <br /> T OWNER/OPERATOR PHONE i <br />_ C CONTRACTOR NAME , PHONE 1 6�2 <br /> O <br /> N CONTRACTOR ADORES ce- <br /> 5 CA LIC t ; CLAS <br /> S�.,G ,Q 410 <br /> T23 } <br /> R INSURER s, c k /ri ta4 S`�et WORK.COMP. <br /> A <br /> C FIRE DISTRICT PERMIT I/INSPTR <br /> I � L <br /> 0 LABORATORY NAME T PHONE,f S fJ 6 D <br />` SAMPLING FIRM SAMPLING METRO .+ t-Z <br /> TANK ID I TANK SIZE CHEMICALS STORED CURRENTLYCHEMICALS STORED PREVIOUSL _ <br /> r. A 39-� /$--? ---- O <br /> - <br /> N 39- <br /> K 39-__--_.--- --•------------- <br /> 34--------------------------- <br /> 39--------------------------- <br />"' LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L -- 00EE ATTACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME ----_- - _ ___-- - _-- ------------------DATE---3 7C..g ------ <br /> N' <br /> . --N <br /> 'APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE'LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN'JDAOUIN 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 I5 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> i„ SUBJECT TO YORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING 02 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 /> �. ' CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGHED _ _ _ _ DATE <br /> ' <br /> SIGNED <br /> '------------------------------------------------------- --------------------------- <br /> CE USE d1tLY--EI♦ 13 046 111BBA <br /> i'.' tttfftiftfffiffffffifffftffifftffff#tiff#t#ffff#fffftiffffffffitftfff#ffffffftftifffftfft#f##t####f##ff###f;ff#fti#tf#fff <br /> �; . SWEEPS E COMP i LOC CODE JOIST CODE AMOUNT DUE AMOUNT RCVD�CKIICASH kCVD BY I DATE RCVD � PERMIT t <br />