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! r-tnfi:lfi:tfi :;;t�lxlfifi tfi tfi tfi t�lfi rfi E�tfi lfi-lfi lfi Ci t�tfi t2-tx lfi� l�t�tfi <br /> -W IPPLIC6 FOR PERMIT SAN JOAQUIN LOCAL HEALTH TRICT r . <br /> l� <br /> UIDERCROVID TANK t: 1601 E HIZELTON AYE., STOCKT611clt: <br /> t: CLOSURE OR IB19DONNEIT t: Telephone (209) 468-3420 t: <br /> Ur-tfi:R:fffftfi.tfi-tfi.fftlirti lfi=tfi tfi=tfi tfi tfi tZ tfi tfi.ty.Rl;.tZ.R:R:ki lfi-tfi.R,ffR7 <br /> IPPLICITION FOR PERMANENTJTENPORIRY CLOSURE OR IBAIDONMENT IN PLACE OF UNDERGROUND 912190OUS SUBSTINCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS 'FROM THE IPPROVIL DATE. DO NOT 11I7E IW 111 SH09 D AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL _ TENPORARf CLOSURE ' ABANDONMENT IN PLICS <br /> EPA SITE S PROJECT CONTACT i TELEPHONE I 9 - <br /> F FACILITY NINE PHONE I <br /> I � o5r- 23 1 ~ a F S' <br /> C ADDRESS <br /> 1 ,C. S lo a A�- <br /> L CROSS STREET <br /> I _ <br /> T OWNER/OPERITOR Fru h 1r H, Cr PHONE I <br /> r rot <br /> C COITRICTOR NINE -- — PONE <br /> a O e� S o o 0 <br /> TCONTRACTOR ADDRESS { CA LIC I �-6 T S CLASS <br /> R INSUREst / YORK.CaNP.1 Gil <br /> a <br /> C FIRE DISTRICT �- PERMIT 1/19SPTI <br /> T <br /> 0 LABORATORY NINE PHONE I <br /> R AC .20 <br /> SINPLIIG FIRMS a T 11 r i1 y SAMPLING METHOD <br /> S <br /> Avvrl S o 11owe <br /> TANK 10 I fill Slie CHEMICALS STORED CURR£ITL CHEMICALS STORED PREY[OUSL <br /> P� Q ✓ <br /> K 39- <br /> 34- <br /> 39- <br /> LIST ADDITIONAL TANK INFORMITION AS NEEDED Of SEPARITS FORK <br /> P IPP20VED _APPROVED WITH CONDITIONS _ DISAPPROVED <br /> L (S 1TTdCANEIf . ITH C01D[fIO1S1 <br /> I PLAN REVIEWERS NINE DdTe <br /> 1 <br /> 1PPLICINT MUST PERFORM ALL YORK II ICCORDINCE WiTA SA1 JOIQUfN COUITI ORDINANCES, STATE LITS, AND RULES 110 REGULATIONS <br /> OF THE Sig JOAQUII LOCAL HEALTH DISTRICT. OWNER OR LICEISED IGEIT'S SICIATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR YRICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY INY.PERSol IN SUCH MIINER IS f0 BECON <br /> SUBJECT TO YORKER'S COMPEISITION LITS OF CILIFORIII.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THIT [N TIE PERFOIXIVCZ OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHILL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LITS OF CILIFORI[I. <br /> CALL 2�7"o E ONS AT LEAST 18 EIOURS IN ADVANCE <br /> rSIGNED . DATE b r J0- P,, <br /> OFFICE USf ONLY--E11-23 044 1211F <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS55SSSSSSSSSSSSSSSSSSSSSSSS5 <br /> c <br /> PS I� COMP InCODE OfST COD AMOUR DUE IMOUIT RCVD CKIJCISB RCYD Br 0119 RCVD PERMIT I <br />