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a ku:a:m,a a it:tv n:a.R:tv n:a t1i kI..1111,a ti-tPA14tv-9: <br /> r. APPLICATIre��OR PERMIT SAN JOAQUIN LOCAL HEALTH DICT <br /> UNDERG!", .J TANK t: 1601 E HAZILTON AVE.? STOCVUICCAS <br /> CLOSURE OVADANDONMENT Telephone (209) 468-3420 t- <br /> 0.1.0:Off Py.Ox PY,OX 010:030:OF.W.Py PV'b OX'OX UKKK Pv.W W P30:W W.tv. <br /> APPLICATION FOR PERnANENTITEMPORARY'CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS. SUBST I ANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> ---- REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE I <br /> C 7G 000 PROJECT CONTACT & E <br /> F FACILITY NAME PHONE I <br /> A <br /> ADDRESS <br /> A SITE EP�11�Cl CONTACT <br /> FACILITY <br /> I <br /> FA P <br /> L CROSS STREET <br /> T -OWNER/OPERATOR PHONE I <br /> Y <br /> C CONTRACTDR NAME <br /> PHONE I <br /> a <br /> N CONTRACTOR ADDRESS7— <br /> CA LIC I <br /> T CLASS <br /> R INSURER .J. W UORK.COMP.1 <br /> A <br /> C FIRE DISTRICT PERMIT #IIMSPTR <br /> T <br /> 0 LABORATORY NAME PHONE 1 <br /> R <br /> SAMPLING FIRM* SAMPLING METHOD <br /> TANK 10 # TANK SIZE CHEMICALS STORED CURRENTLY'CHEMICALS STORED PREVIOUSLI <br /> A 39- jp2 <br /> -------------- <br /> K 39 <br /> 39 <br /> ----------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> APPROVE -A Emu <br /> PPROVED WITH CONDITIONS DISAPPROVED <br /> L <br /> (SEE ATTACH El <br /> PLAN REVIEWERS NAME /"T WITH CONDITIONS) <br /> .. ............ ------------------------DATE---- �'-- <br /> APPLICANT <br /> -----------------------DATE- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANNA REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOL1_-1D'wfWGi*_"�ttRTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SLP'qARNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIROG"OR,SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> ;4tLaWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECI <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADV 7 <br /> E <br /> SIGNED DATE <br /> ------------------------------ ------------ -P <br /> SWEEPS # F COMP # ILOC CODE JOIST CODE AMOUNT DUE AMOUNT RCVO CKI/CASH I RCVD��BY DATE RCV!D PERMIT <br />