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t: tfi. ff ff ff kfi kfi tfi tfifi tfi tfi kfi kfi kfi kfi tfi tfi tfi Yfi tfi Yfi Yfi tfi tfi tfi t tfi tfi tfi �AZ Zi <br />4 APPLICAO, FOR PERMIT t: SAH JOAQUIN LOCAL HEALTNl1AICTt: v <br />t: UNDERGROUND TANK t: 1601 E HIZELTOH AYE., STOCKTOX CA <br />k: CLOSURE OR IBIHOONNEXT k: Telephone (209) 468-3120 t: <br />t� tfi� tfi� tfi� tfi� tfi� tfi� tfi� tfi� kt� tfifi� tfi� tfi� tfi� tfi� kfi� tfi� kfi� tfi� kfi� tfi� tfi� tfi� Yfi� tfi� tfi� kfi� kfi� tfi� kfi� tfi� tfi� tfi� <br />ITIOX FOR PERHANEXT/TBHPORIRY CLOSURE OR IBIXDONHENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br />'RXIT EXPIRES 90 DAYS PROM E APPROVAL D178. DO NOT YR1T8 IN 111 SHADED AREAS. INDICITE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE ABAWDOHNEMT IN PLACE <br />EPA SItE 1PROJECT COXTAC? & TELEPHONE <br />---- G AC oao � 13 a i � �� �� •_ �oo� <br />F <br />A <br />FACILITY HANE_��_�����.`�l/�� PHONE # 2���P.f�= 3%✓� <br />C <br />IDDRESS V C j_01< <br />L <br />CROSS STREET 14Y qq r --;r <br />1 <br />OYNER BR � <br />PHOXB BCq�(�� �.S• %gD I <br />C <br />0 <br />CORTRICTOR NAME i <br />PHONE I <br />X <br />COXIRICTOR ADDRESS <br />CA LIC I <br />CLASS <br />T--- <br />-- — — <br />R <br />INSURER YORK..COMP.I <br />C <br />I <br />FIRE DISTRICT /'�. PERMIT I/[NSPTR <br />0 <br />LABORATORY )(Ahs <br />2 1w � <br />PHONE 1 (2pjc�7 <br />R <br />, <br />SIMPLIXG FIRMi/� /C�iCI� �T SAMPLING H-ETROD ©!� <br />— WM��lIUIVRiDIUI!€WW111IW11ItlI)Oi IWGV9XIgIIRRi9lUYtlB91 <br />TANK ID I TANK SIZE CHEMICILS STORED CURB TL CHEMICALS STORED PRXVIOUSL <br />1 39-_� �- _�e%..--- __� ___ CiltilE t -:7A � <br />^ <br />4_ <br />K 39 --L� <br />_CL_ <br />39 <br />39-- <br />- LIST A11IT NAG TANK IXFORHATIOX AS NEEDED 09 -SEPARATE FORX <br />iWUP�IINIHIW'.IVB,UIIVIUVIWiVIVIIVUIVIWVVVUWUWIUIVfNVVIIVVIVtl. VVVIIVI!kl!IIVBllIliV111UdIIIIIIIVVVVi1WV9 " ' i!VUGNIViV1lIVUlVVIIVI'l�'UWiVIVCU1r1dlIVriIVIVY".IW+UNII�"i�17ikUWVIN.CJI!1111VoIRBVUWUWIViIIIIVIWWdVIViIWBHid'IIGW61)IIWiIIVIVIWIIURVIVVI" ; <br />P APPROVED PPROVED VITH;COXDITIOHS _ DISAPPROVED <br />L (SBE I `CIIMENT YITH. OHDITIOYS) <br />A P:LIH REVIEYERS HINB _ <br />VR�'llffkRVIIDDfViWUIVIIlV1RlVBlIIBkIFI`IGVIOV9R! lkl�lUf91UfU�,NURUi4VldlBl�RIV{VVIIbUXUYHI�IIBU�IUNUW Irwr�yx,:�,dIDR1RIWIVIYVDVDV <br />_ <br />IPPLICAHT MUST PERFORM ALL YORK IN ACCORDANCE WITH SIN JOAQUIN COUXTY ORDIXINCES, SILT& LAYS, IND RULES IXD REGULATIONS <br />OF THE SIN JOAQUIN LOCAL HEALTH DISTRICT. OYNER OR LICEYSED AGENT'S SIGNATURE CERTIFIES THE FOLLOVING: 'I CERTIFY THAT <br />IN THE PERFORHAHCE OF THE YORK FOR YHICH THIS PERMIT IS ISSUED, I SHILL XOT EMPLOY ANY PERSOX IN SUCH MIXXER AS TO BECOH <br />SUBJECT TO YORKER'S COMPEXSITIOX LAYS OF CALIFORXIA.' CONTRICTOR'S HIRIXG OR SUBCOXIRACTING SIGNATURE CERTIFIES THE <br />FOLLOYIXC: 'I CERTIFY THAT IN THE PERFORMANCE OF TIIE YORK FOR WHICH fHIS PERMIT 15 ISSUED, I SHALL EMPLOY PERSONS SUDJEC <br />TO YORKER'S COMPENSATION LAYS OF CALIFORXII. <br />CILI P -01R P-0INSPECTIONS AT LEAST 40 HOURS IN ADVANCE <br />IGHBD_ U 1 <br />1� <br />---- —------- — —.DATE —42 --- <br />OFFICE USE ONLY --811 23 046 12/81 <br />$$$S$$$$$$$S$$$$$$$S$S$$$$S$$SS$SS$$$$S$$$$S$�$$SSS$$$S$$$$SS$$$$$$S$$$S$SS$$$$$$S$$$$SS$S$$$$$SSS$$$$$S$#$S$$$S$$S#$SS$ <br />PEEPS I COMP I LOC CODE DISI CODE AMOUNT DUE AMOUNT RCVD CKI/CASH RCYD BY DATE RCVD PERMIT I <br />I <br />