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' tett t# tt kttt:WMIRfiiMMWWWfWWtfi-tfi WtT-R'Wt1:Wt MOO:P•' <br />Vy <br />APP61C1 ION FOR PERMIT k; 319 JOIQUIN LOCAL HEALTH TR[CT$: <br />t: UNDERGROUND ?INK t; 1601 8 WILTON AVB., STOCK?ON Clt: <br />e CLOSURE OR 1111DONNII? Telephone (209) 168-3120 t; <br />v tt: ttkr- ff-tt-tt. R. Fr-tt. ttt. tt. W. tt. tt. tt. tt-tt: R*- R. Fr. tt. tt.tt. tt. tt. tt: W. tt: M. tt. tt. tt: <br />IPPLICIV OM FOR PBRMANSNT/TBMPORIRT CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND 81211DOUS SUBSTANCES STORAGE FACILITY <br />THIS PERMIT BIPIRBS 90 DAYS FROM THE APPROVAL DITB. DO NOT IRITB IN 111 SHADID AREAS. INDICATE PERMIT TYPE BSLOW: <br />____ RIMOVIL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br />IPA SITE 1 / PROJECT COMTICt i TELEPHONE I -_^C <br />F FACILITY NINEWILI -7A- 12 <br />PEON@ I <br />I <br />C ADDRESS <br />I <br />G CROSS STRIIT <br />I � <br />T OINER/OPSRATOR PROMS I <br />Y i5;�re— 6'Ue-7- Z-4 J C E- I r.2..) 6/- t -2 — -;a, �c- e -l-) <br />C CONTRICtOR NAME <br />! <br />PIONS I <br />N CONTRICTOR ADDRESSCA <br />T --- <br />LIC I <br />CLASS <br />R INSURIR <br />VORK.COMP.I - <br />1 <br />- �_�___ <br />_--------. <br />C FIRE DISTRICT S. j <br />� PSRMIT <br />1/INSP?R <br />0 L180RIT:ORY N1MB00 ® ,4 1 1 PHONE I <br />R <br />SAMPLING FIRM$ 441 <br />t <br />SAMPLING <br />METIOD <br />TANK ID I <br />TIKK SIZE <br />CHEMICALS STORED CURRENTLI <br />CHEMICALS STORED PRSVIOUSL <br />T <br />1 19- 31 <br />et <br />39- <br />39 - <br />LIST ADDITIONAL ?ARK INFORMITION IS NEEDED 01 SEPARITE FORM <br />P4000, APPROVED _APPROVED LITH CONDITIONS DISAPPROVED <br />L (SS ITTACHNENT WITH CORDITIONS) <br />IPLIN REIMERS NINE DITSw- <br />IPPLICINT MUST PERFORM ILL YORK IN ACCORDANCE WITH $10 JOIQUIN COUNTY ORDINANCES, STATE LAWS, AND RUG@S AND REGAL1110S- <br />OF THE SIN JOAQUIN LOCAL HEALTH DISTRICT. OVIER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY ?HIT <br />11 TNB PERFORMANCE OF THB YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER IS TO BECOM <br />SUBJECT TO YORKER'S COMPSISITION LIVS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TNS <br />FOLLOWING: 'I CERTIFY THIT 11 TNB PERFORMINCS OF THE YORK FOR YNICH THIS PSRMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC' <br />TO WORKER'S COMPENSATION LAYS OF CALIFORNIA. <br />CALL OR SP TIONS AT LEAST 48 FIOURS IN ADVANCE <br />SIGNED DATE <br />OFFICE <br />SSSSSSSSSSSSSSSSSSSSSSSSSSS SSSS$SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS$SSSSSSS$SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br />SWEEPS i COMP I LOC CODE DIST CODE` AMOUNT DUB AMOUNT RCVD CKI/CISH RCVD BY OITI RCVD PERMIT 1 <br />_�. _2 'A0 2170 Il <br />