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L�tfi�C;�Cx� �. {.Lfi�Cfi-ciC�Cfifi�Cfi�C2�Cfi�Cfi:Cfi�Cfi�Cfi�C3�t;�C2�Cx�Ct�t$�t�l�ti� �1. :L$� <br /> k APPLI-Mom FOR PERHIT w SAK JaAQUiN LOCAL RRALTHIVISTRIC%, <br /> UNDERGROUND TANK L: 1601 E HAIELTON AYE., STOCKTON CAL: <br /> L: CLOSURE OR ABANOOMNENT L Telephone (2091 168-3120 L: <br /> < C=Cfi�Cfi�Lfi�Cfi�rfi�Cfi�Cfi�Cfi'kfi�C�fikfi�Lfi�kx�Cfi=Cfi�tfi�kfi�kfi�Cfi�C�tfi Cfi�Cfi�kfi�Lfi�kfi�kfi�Cfi�Lfi�tfi�tfi�tfi� <br /> APPLICATION FOR PERMANENT/TEMPORIRY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HIIARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT [RITE IN III SHADKD IREIS. INDICATE PERMIT TYPE BELOW: <br /> EMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE 1 x�Rc, oao�$So�3 PROJECT CONTACT I TELEPHONE 1 <br /> F FACILITY NAMEi�Q � PHOHE tc ` <br /> A <br /> C ADDRESS <br /> L CROSS STREET <br /> 1 i <br /> T OWNER/OPERATOR PHONE I0A. <br /> C CONTRACTOR NIMH' PHONE I <br /> a <br /> N CONTRACTOR ADDRESS j CA LIC 1 CLASS <br /> T ----- <br /> R INSURER VORK.COMP.1 <br /> I <br /> C FIREDISTRICT PERMIT 1/I1SPTR <br /> .. .. <br /> T <br /> 0 LABORATORY NAME , C_ PHONE 1 <br /> R _ <br /> SAMPLING FIRM' SAMPLING METKOD <br /> TANK ID 1 TISK SI1E CHEMICILS STORED CURRENTLI CHEMICALS STORED PREVIOUSL <br /> Emmwwmmmm= <br /> LIST IDDITIONAL TANK INFORMATION IS NEEDED ON SEPARITE FORM <br /> ' '.!/ APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> NT WITH COHDITIOKS)WERS MIME9 9 " rlinili 761N�ti Iiif�RlA <br /> APPLICANT MUST PERFORM ALL YORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SIN JOAOUIN LOCAL HEILTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNISURE CERTIFIES THE FOLLOWING: 11 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 9ECON <br /> SUBJECT TO WORKER'S COMPENSATION LIPS OF CILIFORNIA.' CONTRACTOR'S HIRING OR SUCCOMTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THIT IN THE PERFORMANCE OF THE PORI FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAYS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 IIOURS IN ADVANCE <br /> SIGNED _ . . _ DATE <br /> OFFICE USE ONLY--EH 73 046 12/11 <br /> SWEEPS SSSS#SSS#SSS#SSS#SSSSSSSSSSSSSSS##SSSSSSS#SSS#SSSSSSSSSSSSSSSSSSSSSSS#SSS#SSSSSS#SSSSS#SSSSS#SSS##SSSSSSSSSS#SSSSSS###SSS <br /> r� U I�^^ryCONP 1 I LOC CODELI IfizT�CODE€ AMOUNT DUE - AMOUNT RCYDI �CK€1CAS6 I RCYD BY 7PV <br /> PERMIT 1 <br />