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i- - o T <br />"t t t t t . t It t k� tfi t� tfi k tfi t, l tfi t t� l 1 tZt t t k t� ;Vi j- <br />APPLICATION FOR PERMIT a SIM JOAQUIN LOCAL HEALTH D CT t:I <br />g UNDERGROUND TANK t 1601 E HAZBLTON IVB., STOCKTOY CA t: <br />C CLOSURE OR 131NDOINSIT H Telephone (209) 468-3410 <br />t t� t3 tfi Ry. t:r. t:r. t:r.t1 tvt3.tl*R*tk.tfi.tN.t:r.tl-R,R:Vr-t1.tx.tr. t:r.W.R <br />APPLICATION FOR PERMANSIT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HIZIIDOUS SUBS C��t}S''�trO�ilCB{ TY <br />THIS PERMIT BIPIRBS 90 DAYS FROM THE IPPROVIL DI?B. DO NOT 1117E IN III SHADED AREAS. INDICITE PERMIT TYPE" MOV: <br />Z REMOVIL TEMPORARY CLOSURE _ ABANDONMENT IN PLICS <br />BPA SITE i PROJRCT CONTICT A TELEPHONE i <br />GPS 9 ��� S3Co C �� 4 I- S g r) <br />FICILITY NINE UNo6p,L,, 6j5p,/16jr S-�p-� �,� `cam PHONE i <br />IDDRESS 60.( . }�E'('(�N1A1 t��`+• <br />CROSS STIEBT <br />OWNER/OPERITOR <br />C CONTRICTOR NAME Wf <br />0 400 <br />I CONTRACTOR IDDRESS <br />T <br />R INSURER ahl <br />I <br />C FIRE DISTRICT <br />T <br />0 LIBORITORY NAME 565,gU01A <br />R <br />3INPLIIG FIRMg <br />TANK ID 1 <br />PHONE i <br />(Zo1)) *21- �18'01rC�5 <br />- ' <br />PHONE <br />SIMPLING METHOD <br />TANK SIZE CHEMICALS STORED CURRENTL CHEMICILS STORED PREVIOUSL <br />0 � H'YIIP-0 <br />LIST IDDITIONIL ?INK INFORNITION IS NEEDED 01 SEPARITE FORK <br />P ✓ IPPROVED _IPPRO79D WITH CONDITIO99 DISAPPROVED <br />L (S E ITTICHMENT WITH CONDITIONS) <br />A PLAN REVIEWERS NIMH S��G' T� DITB <br />I <br />APPLICIIT MUST PERFORM ILL WORK 11 ICCORDINCE WITH SIN JOIQUIN COUNTY ORDINIMCES, STATE LITS, AND RULES AID REGULITIONS <br />OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNITURS CERTIFIES THE FOLLOWING: 'I CERTIFY TNA? <br />IN TUB PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH HINNER IS TO BECOM <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CILIFORIII.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNITURB CERTIFIES THE <br />FOLLOWING: 'I CERTIFY THAT 11 THE PERFORMANCE OF Till WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br />TO WORKER'S COMPENSITION LAWS OF CILIFORYII. <br />CALL FOR INSPECTIONS AT LEAST 40 EIOURS IN ADVANCE <br />SIGNED 7. <br />OFFICE B 0NLY--Edd 23 046 <br />SSSSSSSSSSSSSSSSSSS SSSSSSS <br />SWEEPS i I COMP 1 I Loc COD <br />t <br />— (i— <br />/51 <br />SSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSaSSSSSSSSSSS$$$S$$$S$S$$$S$S$$$$S$i$$S$$$$SSSS <br />DIST COOP IMOUNT DUBS IMOUNT RCVD I CK1/CIS3 ( RCVD BY I DITE RCVD I PERMIT i <br />