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• l�t�rt�l� Sfi�tfi�t�efirGifi:l�t�L;FI`iit?r'e;rCi�t'�e;�e�t��t'��rk�tt�ti� i�rt�rtfirt�� <br /> w APPLICIIION FOR PERMIT K SAH JOAQUIN LOCAL HEALTH­DISTRICT w <br /> e: UNDERGROUWO TANK e: 1601 8 HimfoN AVE., STOCKt01 Cir <br /> e? CLOSURE OR IBINDONNBNT G Telephone (209) 468-3120 t: <br /> t t;Mtfi-tfi-ft,W.W.ft-tfi.tfifi.tttfi.tfi:tfi'tfi1a;.t'"TEI.tt;tfi.efi-Yr-t:r-atfty.tr.efi.t*efi,ti: <br /> IPPLICITION FOR PRRMIN8NT/TBMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND s1211DOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EIPIRES 90 DIYS FROM THE APPROVAL DITE. : DO NOT WRITE 19 111 SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> v RBNOYAG TEMPORARY CLOSURE ABANDONMENT IN PLACS <br /> BPA SITE # PROJECT CA,c_ 000 - 201- i3 CONT1Ct i TELEPHONE # ��!•r4�E� gi��-�''� <br /> F FACILITY NAME (21 PHONE 1 _ '7-1(k 19Ce <br /> A . <br /> C ADDRESS �� <br /> I <br /> L CROSS STREKT ON ' p <br /> I - <br /> I OWNERIOPERITOR C-A4A'? zv—.,D & PBOl& a <br /> C CONTRACTOR NAME Sc14I PHONE # 7�f_ <br /> 0 <br /> 1 CONTRACTOR ADDRESS CA LIC 1 CLASS A <br /> R INSURER Fjj,1 E Iju,=/yT- J-I'VS�-LR �UE WORK-COMP.# <br /> 1 <br /> C FIRE DISTRICT b ` PERMIT 1/I1SPIR <br /> T <br /> 0 LABORITORY NAME PHONE I .:2e j _ <br /> SAMPLING FIRM= A-AA C-- SAMPLING HETIOD <br /> TANK ID # TINK Site CHEMICILS STORED CURRENTLI CHENICILS STORED PRI71OUSL <br /> i � <br /> K 39- <br /> ]9- <br /> ]9- <br /> LIST IDDIV OVAL TINK INFORMITION IS NEEDED 01 SEPARATE PORIA <br /> P _ APPROVED _APPROVED WITH CONDITIONS _ DISIPPROVED <br /> L (;n ATTACHMENT WITH COIIDITIONS) <br /> A FLAN REVIEWERS NAME DATE <br /> N <br /> IPPLICANT MUST PERFORM ILL YORK 11 ACCORDINCE WITH SIM JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES 110 REGULATIONS <br /> OF THE SIN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICEWSED IG8NT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THIT <br /> IN THS PERFORMANCE OF THE WORK FOR WHICH THIS PERMITA S ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER 19 f0 BECOM <br /> SUBJECT TO WORKER'S COMPENSITION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNITURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE loll FOR WHICH THIS PERMIT IS ISSUitiD, I SHALL EMPLOY PERSONS SUBJBC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR IINNS�PEEjCTIONS AT LEAST 40 FIOURS IN ADVANCE <br /> SIGNED — <br /> OFFICE USE ONLY--RH 13 016 12181 <br /> SS$SSSS$$S$S$SSSSSSSSSS$SSS$SSSSSS$$SS$TESTES$$$SSSSSS5SSSSSS$SS$SSSSSS$S$$S$SS$SS$SSS$$S$SS$$SSSSSSSSS$SSSSS;$SSS$S#S$$S <br /> SWEEPS # COMP� LOC CODE 0131 C00 IMOUNT OUR AMOUNT RCVD CK1/CASH RCYD BY 011E RCVD PERMIT # <br />