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k t;tfi tt t' VR,tfifi;kyaa:MR:R:t1:tvR:ki:a:tvtvR:R:kfi-to <br /> }. r APPLIC..,awfoR PERMIT �;:rfi: <br /> r: SAN JOAQUIN LOCAL HEALTH uia�CTj.r <br /> r: UNDERGROUND TANK t: 1601 B HAiBLT01 APB., SfOCKTON Cit.. <br /> k: CLOSURE OR 111MD01NErT t: Telephone 12091 168-3410 RECEIVED <br /> t�rfi�rfi�tfi�kfi�rfi�kfi�tfi�kfi�kfi�tfifi�tfi'!fi�lfi�tfi�kfi�rfi�!fi�kfi�kfi�rfi�kfi'kfi�k;�rfi�tfi�tfi�rfi�tfi�lfi'kfi�rfi�tfi� <br /> APPLICATION FOR PERMANENT/TEMPORARY 3 <br /> CLOSURE OR IBIIDOHMENT Ir PLACE OF UNDERGROUND HAZARDOUS SUBSTIrCES STORAGE ICILITI <br /> THIS PERMIT ECPIRRS 90 DAYS FROM THE APPROYAL DATE. DO MOT 111?1 III 111 SHADII BREIS. INDICATE PAMYI$fi:iTAL HEALTH r <br /> PERMITSERVICES 1 <br /> TEMPORARY CLOSURE _ ABAND0IMRNT IN PLACE <br /> BPA SITE 1 CA C 000 Z az I PROJECT CONTACT S TELEPHONE 1 �fE--7T`JrZ1"f m�`� Sazv ��-• <br /> 2U - G <br /> 1 FACILITY NINE C' USD JOZaI ERS PHONE I <br /> ADDRESS <br /> L CROSS STREET <br /> 1 OWNER/OPERATOR PHONE <br /> C CONTRACTOR NAME R NI 20' <br /> O PHONE <br /> T CONTRACTOR ADDRRSS _ $`1`o�Jc"�or✓j CA Cl LIC I CLASS <br /> OS/ C ya <br /> R IrSURRR YP.t <br /> I Ts - ORK.COM_ I✓w ca9�,'� <br /> C FIRE DISTRICT PERMIT I/INSPtR <br /> 1 <br /> O LABORATORY NAME I� PHONE I <br /> l-800 �$ 3 0160 <br /> SAMPLING FIRM �SF�rn SIMPLINc METYops°r`' pa#LPa.l A16 At/Nry /ro-rl v,- vNZee <br /> T "Y AG CAM4 LsD I <br /> T TING YD I TIYK SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PRBVIOUSL F <br /> 31- ' <br /> t, <br /> 3f• . <br /> LIST ADDITIONAL TANK INFORMITION AS NEEDED Or SEPARATE PORN <br /> NYIIDII9IGdIR101tlpIWUkIiNkOlpllNll➢llIOItlRIWtlkWIDrIOIWf@0dn1411�IlYIrooCIWIWIINIINIY101RGN0YIdIDf� <br /> P APPROVED _APPROVED WITH CONDITIONS _ DISAPPROVED <br /> L (SRR ITTACHMENT WITH CONDITIONS) <br /> I PLAN REVIEWERS MIME ' DAfR Z <br /> �1IfYN101Y1'VIEIl110111lIi1�l1 `. <br /> APPLICANT MUST PERFORM ILL WORK IN ACCORDANCE WITH SIN JOIQUIM COUNTY ORDINANCES, STATE LAWS, AMD RULES 110 REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER 09 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY Tilt <br /> 11 TYE PERFORMANCE OF THE WORN( FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY 101 PERSON IN SUCH NIrNER 1S TO BECOH <br /> SUBJECT TO WORKER'S COMPENSATION LAYS OF CALIFORNIA-' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGIITURR CERTIFIES TRE <br /> FOLLOWING: 'I CERTIFY THIT 11 THE PERFORMANCE O <br /> TO YORKER'S COMPENSATION LITS OF CILIFORNII. F THE WORK FOR WHICH THIS PERMIT [S ISSUED, I SHALL EMPLOY PERSONS SUBjRC, $ <br /> CALL FOR INSPECT NS AT LEAST 48 HOURS IN ADVANCE <br /> SIGIRD __-• `DItR _� <br /> OFFICE USE ONLY--BH 23 041 12/11 - <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS#SSSSSSS#SSSSSSSSSSSSSSSSSSSSSSS$SSSSSSSSSSSSSSSSSSS#SSSSSSSS##S#SSSSSSSSSSSS <br /> SWEEPS I COMP { LOC CODE DIST CODEII AMOUR DUB AMOUNT RCVD CKI/CASE I . RCPD BY DIB CVD PERMIT ! <br /> X79 ���0 D/ 19�1.�_���°� <br /> _ �t. <br />