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ff R: <br /> Ik 'PPLICIIIONFOR PERMIT SIX JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND WK 1601 E HIZELTON IVB., STOCKTON Clt: <br /> CLOSURE OR IIINDOMMEIT Telephone (209) 468-3420 <br /> ti:ti:R:tit-'ti:ti:ti:t-1:ty.R:R:ft.t-1:ti:ti:R:R:R:kY R:kl:R:ti:R:t:r-til: <br /> IPPLICITION FOR PRRMANRXT/TFXPORIRY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HIZIRDOUS SUBSTANCES STORIGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE IPPROVIL DATE. DO NOT 11179 IN III SHhDID AREAS. INDICATE PERMIT TYPE IRLOW: <br /> REMOVAL TEMPORARY CLOSURE ^ ABANDONMENT IN PLICI <br /> Epls'Tll c l K 0ooi5_qoS3 PROJECT CONTICT 4 TELEPHONE I <br /> F FACILITY NAME 0)Co(\1[40p, Vjooj)S PHONE <br /> I — ao� L(76 -197-3 <br /> C IDDRESS 3 9 00 WAGNE-L HE76HTS kb , STOCK—16/VI (A- <br /> L CROSS STRAIT <br /> I <br /> T OWNER/OPERITOR 0"C 0 t\J f\102 WOO S lIQ C - PHONE I <br /> s_T_- j_OsCP4 S HERL7 H Cftf,E Coil `X67 -63yS- <br /> OC CONTRACTOR "ME WOL11\1 � So/\J,5 /Af PHONE I dO? 6 7—� 1 <br /> I CONTRACTOR ADDRESS p®, 60 - <br /> 2�1C CA LIC I <br /> R INSURER T�—( C/�V CL- YORK.COMP.1 <br /> A <br /> C FIRE DISTRICT —Ie)L F 01'4 PERMIT I/INSPTR <br /> ? <br /> 0 LABORITORY WINE Cj��f� /},q//�L�il /�7�;�Co <br /> PHONE I <br /> SAMPLING FIRMt 4- A530 C• SAMPLING METHOD <br /> TANI ID I TANK SIZE CHEMICALS STORED CURRENTLI CHEMICALS STORED PRIVIOUSL <br /> 39- <br /> I 39- <br /> 39- <br /> 139 LIS? IDDITIONIL TANK I INFORMATION IS NEEDED ON SE I PARITO FORM <br /> MUM ulfluidummimmuN 1110 WUWUWIUUWWWIUWWIUUIiIUuuWWUWIIWUUWIIUUWUutlIIWUUUUIUUWIIWIWuutUWUWIuUUUWUIVUVUIWIIIUIIWUWUWuuUUWUWWWUUIUWIUUIUUWURIIWIIUWWWJUUUWIIUUUUWUWW I) <br /> P APPROVED IPPROVRD WITH CONDITIONS <br /> DISAPPROVED <br /> A ACHMENT WITH CONDITIONS) <br /> REVIEWERS HIM <br /> PLAN R ;ml <br /> -- IUIIUL'WWIIUWUWWWIIWiUllUWWW{tlUUIWWIUUUWURIIUUUWUWUWUUWIIWllYIIIYIIUWIWRURUUDUWWWWUWWWWUUUUUIUUWUllWWIUUUUWUWURIURIWIIUIIWL'UUiWuullUlUUu1lWUWUWIUIUnIUWWUIIIWUWuuL'IUutlUUUWWIWWWWIWWWIIWWWIUYWWYUWIWWIW <br /> IPPLICkHT MUST PERFORM ILL YORK IN ACCORDANCE WITH SIN JOIQUIN COUNTY ORDINANCES, STATE LIPS, IND RULES IND REGULI?IONS <br /> OF THE SIN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGIITURR CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT 13 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOMI <br /> SUBJECT TO YORKER'S COMPENSATION LIPS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT If THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJRCI <br /> TO WORKER'S COMPEXSITION LAWS OF CALIFORNIA. <br /> CALL FQR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> S IGNED <br /> OFFICE USE ONLY-EH 23 046 12181 <br /> SWEEPS ICOMP I] LOC <br /> DIST Col AMOUNT RCVO IMOUMT DUE CKI/CASH RCvD BY j 0119 RCVD PERMIT I <br /> .[—CODE <br /> �_ — __ I <br />