Laserfiche WebLink
t; APPLICATIOr ' 'ERMIT t: SAN JOAQUIN LOCAL HEALTH DISTR' <br /> t: UNDERGRbr.d TANK �: 1601 E HAZELTON AVE., STOCKT <br /> CLOSURE OR ABANDONMENT k; Telephone (209) 468-342U`''f t: f <br /> ' Y:Y�:1}:1}:!}:Y}:!}:Y}:hl:Y}:Y}}:1}:}}:1}:►}:Y}:!}:►�:Y}:>}:►}:}1:!?:}}:Y):1}:/�:1):Y):Y}:►}:1):�}: "R <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS.PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: f <br /> _ZA REMOVAL _ TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE 10a t G yos PROJECT CONTACT d TELEPHONE I Ws-s e„ GA.-rhMSE c✓1C4� <br /> Cf1 C D - - - --- - <br /> F FACILITY NAME 14.F_ S PHONE I (� j q) f p, y 12Y <br /> A ---- — —---�- — <br /> C ADDRESS _ <br /> jQ��a�.�(2cZ__�_�9�rS!_Q�J <br /> L CR05S STREET <br /> I — ----- —_- - <br /> T OWNER/OPERATOR PHONE i <br /> Y c � -r �� s �0 9'3 <br /> G CONTRACTOR NAME PHONE I <br /> r�,r� S 2�v1 ,� 2v 1 1'/"F z <br /> N CONTRACTOR ADDRESS z-73.5_ 1_5`PE a '5 X_ CA LIC ICLASS <br /> T �sT0eJ�t: Zv i yt`�IJS1 C-d/-D <br /> R INSURER S WORY..COMP.,I <br /> C FIR <br /> E DISTRICT <br /> PERMIT #/INSPTR sa,& vrroa,z Te�K, wrr <br /> T w i 1_ r{E s�r•,o 4-E Y c c r+•,v—sn t. <br /> O LABORATORY NAME 1 (F}T�rL GJdFZN,� ^- �PHONE # ��U 92 83e 350 <br /> R Iv r. . � t/ C s � _. <br /> SAMPLING FIRMt SAMPLING METHOD <br /> TANK ID I TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSL <br /> T c� <br /> A 39-_Aa'Z-L_`-_ - ---- �d ,DL �- <br /> K 39- --- -- — ---- <br /> -------------------------- <br /> 39 <br /> ---------------------------- <br /> 39- — <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> • �� �YYfINiIFI<II�WYIniIIiYIktlIIBiNVll4H1lIIAiI1WIILYtlIiIN ' <br /> P APPROVED APPROVED WITH CONDIIIONS DISAPPROVED <br /> ' L (SE�TTACHMENT CONDITIONS) <br /> A <br /> PLM REVIEWERS NAME ---- ��__ DATE <br /> SWIIWSWSIWSWSSWIISSSWSSWISID�Wmi�IIWiW01iII�YiIIIIIIDIIVIIi�IViii <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN 10A9UIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA, <br /> ` CALL FOR INSPECTIONS AT LEAST 4e HOURS IN ADVANCE <br /> SIGNED-, DATEZ _ <br /> W ................................................... <br /> Of OS ONLY--Eb 23 OYS I1I88 <br /> SsffffffffffffSSSSSSSSSSSfSfSSSSSSSSSfSSSSfffffSSfSffffifffffffSSSSSSfifffffififffSffffSSSSffSffffSSSSfSfSfSSSSfffSffSSSS <br /> SWEEPS # MP # LOC CODEDIi� 1oaDUE JAMOUNT Q°OCU KIIIJeDA <br /> aY TE 9cvD USH I <br />