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UNUEHURuUNU 'TANK ./ 1bUl E HAZELTUN Abp/, STOCKTON CA <br /> jj CLOSURE OR-ABANDONMENT {i -+ Telephone ( 209 ) 458 392+? 11 <br /> APPLICATION FOR PERMIN6IT/fBMPORIRi CLOSURE OR IBIIDOINUT IN ?LICK OF UNDIRGROUND HAZARDOUS SUBSTANCES STORAGE FICILITT <br /> TO'S PERMIT WIRES 10 DAIS FROM THE APPROVAL DATE. DO NOT 11179 11 IIT SHAND ARZIS. INDICATE PERMIT TYPE BZLOY: <br /> EMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> - F PROJECT CONTACT PHONE N <br /> A -� _ X4.IN/«01✓ L <br /> C FACILITY NAME ADDRESS <br /> L OWNER �^ <br /> ' I 411 ADDRESS <br /> y <br /> �I T j' CROSS STR T I PHONE N / <br /> Y <br /> C CONTRACTOR NAME CQ i PHONE N -' <br /> 0 <br /> T I CONTRACTOR ADDRESS <br /> - _Tel_._/Y_�/�// /�p //QG�� + CA LIC <br /> -- - <br /> R LIC CLASS WORK . COMP . N INSURER <br /> A �_-_ '� <br /> -_-� <br /> C FIRE DISTRICT D PERMIT N <br /> 0 LABORATORY NAME PHONE M gal <br /> R <br /> SAMPLERS NAME l SAMPLING METHOD <br /> C VOLUME CHEMICALS STORED 1 DATES STORED CHEMICALS STORED <br /> H ;PLAN <br /> CURRENTLY PREVIOUSLY <br /> m OIL TO <br /> C TO <br /> -To <br /> - <br /> A <br /> f TO 1I <br /> L LIS ANY EXTRA TANKS ON A SEPERATE SHEET <br /> P 4 <br /> i L (SEE ATTACHMENT WITH CONDITIONS) <br /> A REVIEWERS NAME qjy G;t1�/ <br /> N DATE <br /> APPLICANT MUST PERFORM ALL PORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDIFINCES, STATE LAWS, AND RULES AND RECULA1fONS <br /> OF THE SAM JOAQUIN LOCIL HEALTH DISTRICT. OYMER OR LICENSED AGENT'S SIGU TURF CERTIFIES TOR FOLLOYINC: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE FORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MINNER 1S TO BECOME <br /> SUBJECT TO FORIMIN'S COMPENSATION LAYS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGO170RE CERTIFIES THE <br /> FOLLOWING: '1 CERTIFY THAT IM THE PERFORMANCE OF THR YORK FOR ERIC# THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT <br /> TO YORKMAN'S COMPENSATION LAYS OF CALIFORNIA. COMPLETE DRAIING 01 ATTACKED PLOT PLAN SKEET. <br /> CALL FOR ALL NECESARY INSPECTIONS AT LEAST 98 HOURS IN ADVANCE <br /> SIGNED X TITLE :_ -_ DATE: I�a <br /> ACCEPTED B TITLE: DATE: _ <br /> j <br /> f <br /> IYTI�IIAMAIP�MIviwA�R�MCMm�iwnMn..am.n...n..�..............«..�.......... -...............—.—.._...... � <br />