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t:tlrtir LIwwrok <br />ki:tvtit. tfi:Wtfi:kVtl;:k :ak�:t:r.kl::ty.". q 0k� wkv: <br />APPPERMIT w SAN JOAQUIN LOCAL HEALIN DI ICT r: <br />t: UNDERGROUND TANK t: 1601 B RAZBLtON AVB., STOCKTON CAI: <br />k: CLOSURB OR 1111DONME1t t: Telephone (209) 168-3120 t: <br />k: R: tl:: kfi: k3: W. Vf-k : kfi: kl::1W. kl;: kl;: A'tx: tv. kl:: kfi: k:k: El:: t:r. W. t3: ff 0 f tt:0: W. W. kl: R:0: <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARD tY <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DA?R. DO NOT I11TB IN All SNADID AREAS. I RMI? ?YP B <br />REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLICB MAY 1 1989 <br />BPA SITE 1 ' c-] q — 16001 PROJECT CONTACT i TELEPHONE t <br />FACILITY NINE OG �'T.�G',G' TOit1 AIPRONI <br />I <br />ADDRESS �'? ,�zoSo ��1.��.5'e-� <br />CROSS STREET-ifii���`/ <br />OVNBR/OPERATOR O¢ j�5-7,--A-zawv <br />PHONE <br />TH <br />CONTRACTOR NAME S�5V ri PROVE 1�al <br />CONTRACTOR ADDRESS "0? $_ 474WICWWS7 CA LIC 1 <br />INSURER ��.�z.�.si?—�� �9���''� �-� OO VORK.COMP.1 <br />FIRS DISTRIC! Q �U PERMIT 1/[1SPTR l,([v <br />LABORATORY MIME ��� PHONE 1 <br />�2 5 1 SAMPLING METHOD <br />TANK ID TANK SIZE CHEMICALS STORED CURRENTLI CHEMICALS STORED PRIVIOUSL <br />1 39- <br />139- <br />1 39- <br />39- <br />- <br />LIST ADQITIORAL TANK INFORMATION AS NEEDED ON SEPARATE FORK <br />P APPROVED 'APPROVED VITO CONDITIONS _ DISAPPROVED <br />L (S B ATTACHMBN? WITH CONDITIONS) <br />A 111,11 IMBIBES NAME <br />N <br />APPLICANT MUST PERFORM ALL WORK 11 ACCORDANCE WITH SAN JOAQUIM COUNTY ORDINANCES, S?ITS LAWS, AND RULES AND REGULATIONS <br />OF TUB $AN JOAQUII LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br />IN TNR PERFORMANCE OF TNB WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY IVY PERSON IN SUCH MANNER AS TO BECOM <br />SUBJECT TO WORKER'S COMPSISATION LAVS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THB <br />FOLLOVING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJBC <br />TO VORKBR'S COMPENSATION LAVS OF CALIFORNIA. <br />CALL FOR INSPECTIONS AT LEAST 40 IIOURS IN ADVANCE <br />SIGNED DATE <br />OFFICE USE OILY --EH 23 016 12/11 <br />$SSSS$SSSSSSS$SSSSSSSSSSSSSSSS$SSSSSS$SS$SSS$SSSSSSS$SSSS$S$$S$SSSSS SSS$$$SSS$SSSSSSS$SSSS$SSSSSSSSSSSSS$SSSSSSSSS <br />SWEEPS I_I_.COMP ( I LLOOCC CODEISTTCCODS' IMOUNT AMOUR RCVD CIt ASH I RCVD BY DATE RCVD I PBRMtf <br />