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UNDERGROUND TANK" II 1601 E HAZELTON An. , STOCKTON CA II <br /> I� CLOSURE OR ABANDONMENT��--Telephone (209 ) 468-3428 <br /> APPLICATION FOR PERMANSIT/TEMPORARY CLOSURS OR ABANDONMENT IN PLACE OF UNDERGROUND 111110096 SUBSTIECES STORAGE FACILITY <br /> THIS PERMIT RIPIRES 90 DAYS FROM THE APPROVAL DIVE. DO NOT 11179 11 IBI SHIIWD ARRIS. I101CITI PRRNIT TIPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> (� F PROJECT CONTACT PHONE # <br /> A PHONE <br /> C FACILITY NAME ADDRESS slit l <br /> I W M 3u i�cQFrs 5 w s ?US r <br /> L OWNER ADDRESS <br /> i I _ ul c)e✓ PO Bc»C 1107 j53 <br /> T CROSS STREET PHONE # 3 5 (J/ 7:-)- <br /> Y <br /> ZY <br /> C CONTRACTOR NAME PHONE # <br /> 0 <br /> T CONTRACTOR ADDRESS 3h ( JY1vtt <br /> CA LIC # 9�� c <br /> R LIC CLASS WORK . COMP . # INSURER <br /> C FIRE DISTRICT PERMIT # <br /> T I mac. 1=a c N o l-' -- — -- -- <br /> 0 LABORATORY NAME CGl �1 'IV V. PHONE # 2nd / ` 8 s j3CKD <br /> R --— <br /> SAMPLERS NAME SAMPLING METHOD <br /> '11111 <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID # CURRENTLY PREVIOUSLY <br /> E ---- -- — - --- — <br /> M / OOU ��/�'SF TO <br /> I TO <br /> C TO <br /> A TO <br /> L LIS ANY EXTRA TANKS ON A SEPERATE SH ET <br /> P <br /> L (SEE ATTACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME cT/}/M = /--/+,/d A- DATE 7- <br /> N N <br /> APPLICINT MUST PERFORM ALL FORE IN ACCORDANCE /NTH SIT JOAQUIN COUNTY ORDIWINCSS, STATS LEIS, 110 RULES IND 19CULITIOIS <br /> OF THE SAN JOIQUIN LOCAL HEILTH DISTRICT. OWNER OR LICENSED IGEWT'S SIGIITURS CERTIFIES TB1 FOLLOWING: of CERTIFY THAT <br /> IN TRE PERFORMAICR'OF TWE WORK FOR WHICH THIS PERMIT IS ISSUED, I $BALL 10f EIPLOY INT PERSON 11 SUCH MINNER IS TO RECONS <br /> SUBJECT TO FOREMAN'S COMPENSATION LIWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACHIG SIGN/TURF CRRTIPIES TBR <br /> FOLLOUNG: 'I CERTIFY THAT IN THE PERFORMINCR OF THE FORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br /> TO FOREMAN'S COMPENSATION LAYS OF CALIFORNIA. COMPLETE DRAWING 01 AT71CRED PLOT ?LIN SHEET. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED X TITLE: DATE: <br /> ACCEPTED BY TITLE: DATE: <br /> /Co k ✓=C iitisow 6 f <br /> AII®WAIIIIIWAAtlAA�IAIIAA .�PAAMINMIIAAAWNAIAIP@IIAI�R <br />