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` t'ITtt'tYtI t:tt'tt-tit.tt.tt'tvtvtvtt'tt'tt.tt'tytvtt tv tv tv tt'tyt'ti:ti: <br /> APPLICAW FOR PERMIT `. $11 JOAQUIN LOCAL HEALTH QRICTV. <br /> t UNDERGROUND TANK t: 1601 B HAIRLTON AVB., STOCKTON CA t; <br /> t; CLOSURE OR 1110DORMENT g Telephone (2091 160-3220 t <br /> t'IT.tt.tt'tt:tt'IT.ti:tt'ti:ttt'tt tt'tt'tt:tt'tt'6t'tt'tt'tt'tt'ti:tt'tt.tttt'tt:tytt'tt'ti,tt: <br /> APPLICATION FOR PIRNANBNT/11HPONIR► CLOSURI OR ABANDONMENT IN PLACE OF UNDERGROUND RAIINDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT BIPIRBS 90 DAYS FROM TOR APPROVAL Dill. DO NOT TRITE IN ►IT SHADED AREAS. INDICATE PERMIT TYPE IBLOV: <br /> REMOVAL tEMPORART CLOSURE ABANDONMENT IN PLICA <br /> EPA S[TB I PROJECT CONTICT A TELEPHONE I _ <br /> P FACILITY NAME 67 PHONE <br /> C ADDRESS <br /> L CROSS Still? <br /> T OVNER/OPRRITOR PHONE I <br /> ® COItR►CtOR MINI 7-, LIN �� _ PHONE I A <br /> T CONTRACTOR IDDRBSS CA LIC I �� s S.. C SI <br /> — — __ <br /> 40 <br /> I INSURRR A =1d M Z VORK.COMP.I <br /> C FIRE DISTRICT 'rvR* PBRNit 1/INSPTR <br /> 0 LABORATORY NIMB PRONE I p®p S G�� <br /> R -- --� Tc 1 La — <br /> SAMPLING FIRM® L Te G — SAMPLING METIOD� <br /> TANK IO 1 TANK SIZE CHEMICILS STORED CURREIII'Ll CHEMICALS STORED PRIVIOUSL <br /> JAPLAiI.RIVIEVRIS <br /> - _ __ _ O o00 .tr1%� 1 �1 31 <br /> - D D bt ADDITIONAL ?ARK INFORMATION AS NEEDED 01 SEPARATE PORN <br /> APPROVED _ APPROVED VITH CONDITIONS DISAPPROVED <br /> (SHB ATTACHMENT VITH COYDITIOISI NINE _ DAtR <br /> IPPLICANT RUST PERFORM ALL YORK 11 ACCORDINCE VITR SAN JOIQUIN COUITT ORDINANCES, Still LIPS, AND RULES IND PEGULITIONS <br /> OF THE SAN JOAQUIN LOCAL IBALIN DISTIICT. DINER OR LICENSED AGENT'S SIGIATURI CERTIFIES THE POLLOVIVG: It CERTIFY THAT <br /> (I TNR PERFORMANCE OF THE YORK Vol VVICN THIS PERMIT IS ISSUED, I SHALL 101 EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br /> SUBJECT TO TONKIN'S COMPENSItION LM OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNAtURB CERTIFIES THE <br /> POLLOVIIG: 11 CERTIFY ?HIT 11 TNB PERPORNINCB OF till VOR1 FOR TRICK THIS PERMIT IS ISSUED, t SHALL EMPLOY PERSONS SUBJEC <br /> TO VORKER'S COMPENSATION LIVE OF CALIFORNIA. <br /> CALL FOR INSPECT ONS AT LEAST 40 HOURS IN ADVANCE <br /> SIGNED <br /> OFFICE USE ONLY--BH 11 016 12/11 -- <br /> SSSS9SSSSSSSSSSSSSSSSSSSSSSSSSSSS3SSSSSSSSSSSSSSSSSSSSSSSSSSSBSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SVBEPS 1 COMP I LOC CODE DIST COD OUNT DUB I AMOUNT RCVD CKI/CASH RCTD BY Dill RCVD PERMIT I <br /> _ 1 <br />