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rtie R it <br /> V APPI,601 FOR PERMIT „ SAN JOAQUIN LOCAL H610W.StRICT w <br /> t UNDERGROUND WE t 1601 R W ELTON All., STOCKTON Cl o- <br /> CLOSURE OR 111NDoNKBNt a Telephone (209) 160-3120 t <br /> wIrkintik;t1txt:'tyR1tiRt:rRfttit3ttRttRtit;RRRRtItiRRti <br /> APPLICATION FOR PIRMANSNT/tBMPOR111 CLOSURL OR ABANDONMENT IN PLACE OF UNDERGROUND HIEIRDOUS SUBSTANCES STORAGE FACILIft <br /> THIS PERMIT 8IPIIES 90 DAYSFROMTHE APPROVAL DATE. BO NOT 11117E If All SIIAD11 AREAS. INDICATE PERMIT TYPE IRLOY' <br /> RBMOYIf. TEMPORARY CLOSURE ABANDONMENT IM PLACE <br /> EPA SITE I CA / �r7 g�o 522 PROJECT CONTACT & TELEPHONE I Sf7C CG <br /> F FACILITY MAKE s PHONE I <br /> I <br /> C 1DbR8SS <br /> L CROSS S11111 <br /> T 011111/OPERATOR Pools I <br /> C CONTRACTOR NAME <br /> 0 ' <br /> N CoNt"CTOR ADDRESS2-42 <br /> OG CA LIE I3 CUSS, <br /> T <br /> R INSURER �� � YORK.COMP.I PJH��_Jr�y�/��_Q�3 <br /> 1 <br /> C PIER DISTRICT S. J �U� c p PERMIT I/INSPTR <br /> T -- / _ <br /> 0 LABORATORY NINE J!� PHONE ! � 99,5 <br /> R <br /> SIMPLIYG FIRM= „�� ���! ���f//� SAMPLING METHOD <br /> mmmumAmmmam <br /> TANK ID I TANK SITE CHEMICILS STORED CURRtItLI CHEMICILS STORED PRBYIOUSL <br /> t G' c.Lu <br /> N 39- <br /> ZI 39-_L23� — 3 " r• <br /> 34- <br /> 39- <br /> LIST IDDITIONIL ?INK IMFORMITIOH AS NREDBD ON SEPIRITE FORM <br /> ORO <br /> P -- APPROVED _IPPROf1O PITH CONDITIONS _ DISAPPROVED <br /> L (48 1?tICMKEHt YITN C08DItIOHS) <br /> A PLAN RBYIBYIRS NAME l <br /> N <br /> 1PPLICINT MUST PERFORM ALL YORK 11 ACCORDANCE 1111 $10 JOAQUIN COUNTY ORDINANCES, STATE LIPS, IND RULES IND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OYNER OR LICENSED IGENT'S SIGIIIURE CEITIFIES THE FOLLONING' 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE YORK FOR YHICH THIS PERMIT IS ISSUED, I SHILL NOT EMPLOY ANY PERSON IN SUCH M111121 1S TO SECOM <br /> SUBJECT t0 YORKER'S COKP8NSATION LAYS OF CALIFORNIA.' COMTRICTOR'S HIRING OR SUBCONTRACTING SIGNITURB CERTIFIES TRE <br /> FOLLOVING: 11 CERTIFY ?HIT IN THE PERFORMANCE OF TINE PORI FOR WHICH TMIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO YORKER'S COMPENSATION LAYS OF CILIFORHII. <br /> CALL OR SP TIONS AT LBAST 40 HOURS IN ADVANCE <br /> f, <br /> SIGNED DATE 11-1:0e—or <br /> OPFICB S --EH 3 61 1 <br /> $$M$9SSIS8SSSSSSSSS$9SSiS 555SSSSB99s m$$39SSS3S;ISSSSSSSSSSSSSS6SS$SSaSSgSixSSSS6SSSSSSSSSStSSSSSSSSSiSiSSSSSISISSSS <br /> SYREPS I COMP I JLOC CODE IDIST COD IMOUNT DYE IMOUNT RCVD CII/CASE 011E RCYD PERMIT 1 <br /> 7 �.._ _ zo �? 33.2.4 Z 7d'" .z'70 �' �o'7 1_:�W—1 ► 1 <br />