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UNDERGROUND TAN&, II 1601 E HAZELTON lr.d.., STOCKTON CA <br />CLOSURE OR ABANDONMENT Telephone (209) 968-3928 <br />APPLICATION FOR PSRMINSNT/TEMPOIIRT CLOSURE 01 IBIIDONMSNT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTUCSS STOHIGS FACILITY <br />THIS ?IBI,LT SIPIRHS 90 DAIS FROM TBE APPROTIL DATE. DO NOT FRITS IN 1I1 SHISID ARZIS. IHDICITH PEIMIT TIPS BSLON: <br />REMOVAL TEMPORARY CLOSURE _//�\1 <br />ABANDONMENT IN PLACE <br />F <br />A <br />PROJECT CONTACT//,�, & <br />PHONE # <br />C <br />FACILITY NAME �SCHd <br />ADDRESS �c3s S? <br />�6tJ/-a72 <br />I <br />�- <br />— <br />L <br />OWNERee <br />ADDRESS <br />II T <br />CROSS STREET <br />Y11 <br />— --- <br />- <br />r <br />I( C <br />0 <br />CONTRACTOR NAME <br />PHONE #/ <br />yGo2 9'7// <br />N <br />CONTRACTOR ADDRESSCA <br />LIC # c <br />T <br />ajf�i� <br />R <br />LIC CLASSWORK. <br />COM----- <br />If <br />INSURER <br />A <br />-- — S� <br />F4J0 !d 6 31 <br />mitis <br />_ <br />C <br />FIRE DISTRICT <br />PERMIT <br /># <br />T- <br />0 <br />R <br />LABORATORY NAME 7202 /yG <br />I PHONE # <br />— <br />SAMPLERS NAME <br />SAMPLING METHOD <br />C <br />K VOLUME <br />CHEMICALS STORED <br />DATES STORED <br />CHEMICALS STORED <br />H <br />ID # <br />CURRENTLY <br />I <br />PREVIOUSLY <br />M <br />TO zr~,o2) 6 <br />I <br />TO <br />C <br />TO <br />A <br />TO <br />L <br />LIS ANY EXTRA TANKS <br />ON A SEPERATE SH <br />ET <br />PRVFKUVZD <br />L' Aevmuv6U,,w1111 <br />11111111111 <br />L <br />(SEE ATTA NT <br />WITH TNDITNS) <br />�y <br />A <br />PLAN REVIEWERS NAME <br />C_— <br />DATE od <br />N <br />L <br />-- <br />APPLICANT MUST PERFORM ILL FORS IN ICCOROINCE FIT# SAN JOAQUIN COUNTY ORDINANCES, ST/TE LARS, 110 RULES ARD RIGULITIONS <br />OF THE SIN JOAQUIN LOCIL HEALTH DISTRICT. OINIR OR LICENSED AGENT'S SIGIITURE CIITIFISS TBR FOLLOIING: 61 CERTIFY ?HIT <br />IN THE PERFORM1ICr OF THE YORK FOR IHICB THIS PERMIT IS ISSUED, I SHILL NOT EMPLOY INT PERSON IN SUCH MINNER IS TO BECOME <br />SUBJECT TO YORKMIM'S COMPENSITION LIVS OF CILIFORNII.' CONTRACTOR'S HIRING OB SUI-CONTRICTIIG SIGNATURE CERTIFIES ?BE <br />FOLLOUNG: 11 CERTIFY THAT IN THE PERFORMANCE OF THE FORK FOR IHICH THIS PEIMIT IS ISSUED, I SBILL EMPLOY PERSONS SUBJECT <br />TO FORKMIN'S COMPENSATION LITS OF CALIFORNIA. CONPLETE DRIVING 01 ATTICNED PLOT PLIN SHEET. <br />CALL FOR/ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br />SIGNED X �n/w�=--<\J�- TITLE: /C. DATE: <br />ACCEPTED B TITLE: DATE: I L <br />