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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND TANK 1601 E HAZELTON AVE. , STOCKTON CA <br /> CLOSURE OR ABANDONMENT Telephone ( 209 ) 968-3920 <br /> IPPLICITION FOR PIIM1MIIT/TEMPORIIT CLOSURE OR 16110018111 IM ?LICE OF UNDERGROUND 1111RDOUS SUBSTINCES STORIGE FICILITT <br /> THIS PIRMI IPIRES 70 D1TS FROM THE 1PPROVIL BITE. DO NOT WRITE 11 IIT SNIDER IRE1S. INDIC/TE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACT '�kCk PHONE <br /> A <br /> C FACILITY NAME 5nPHCMS aNcooeA&C ADDRESS <br /> I <br /> L CROSS STREET PHONE M� <br /> I <br /> T OWNER J PHONE M _/ <br /> Y S9 E JS /kWCF(OP-/kfxE <br /> C CONTRACTOR NAME W6-5 i 'J l lege PHONE 1 2Lrj1 11-fe) -Cala <br /> 0 <br /> w N CONTRACTOR ADDRESS - �35 ICP e J2iv� SUITS <br /> R LIC CLASS WORK. COMP. I cmPO4cyq - '{ INSURERS + Ensu e, ck � <br /> A _ YP -5• �a-vyr <br /> C FIRE DISTRICT PERMIT M <br /> T <br /> 0 LABORATORY NAMEC�1L r� PHONE N / <br /> R <br /> SAMPLERS NAME SAMPLING METHOD <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID N CURRENTLY PREVIOUSLY <br /> E <br /> M TO ow J <br /> I CrA-yll Iof 7 TO „ Ui: <br /> C 3 'o GR -�SinfF ----7 —TO 0, <br /> A TO <br /> L LIS ANY EXTRA TANKS ON A SEPERATE SH ET <br /> iW tl <br /> P F AVFKUvk Y 'tl" Niii '7 ? <br /> L (SETACHIN� WITH CONDITIONS ) <br /> ME <br /> A PLAN REVIEWERS NALQT_ p DATE <br /> N <br /> I <br /> IPPLICINT MUST PERFORM ILL foil IN 1CCORD/NCE WITH SIR JOIQUIN COUNTY ORD[NINCIS, STITH LIVS, IND RULES IND RICULITIONS <br /> OF THI w JOIQUIN LOCIL 111LTN DISTRICT. 01112 OR LICENSED IGI1T'S SIGNITURE CIITIFIES TER FOLLOWING: 'I CERTIFY THIT <br /> If TIE PE2FOR9/1C/ OF IRS WORE FOR WHICH THIS PERMIT IS ISSUED, 1 STILL NOT EMPLOY INY PERSON it SUCH MINNEI 1S TO BECOME <br /> SUBJECT TO WORINII.'S COMPEI3ITIO1 III$ OF CIwFORIII.' CONTIICTOR'S HIRING 02 SUI-CONTRICTING SIGNITURR CIITIFIES THE <br /> FOLLOVINC: of CERTIFY THIP IN THE PERFORMINCE OF THE FORK FOR WIICI THIS PERMIT IS ISSUED, I SHILL EMPLOY PERSONS SUBJECT <br /> TO WOPIMIW'S COMPIISITION LIVS OF CILIFORNII. CONPLITE DRIVING ON IffICHED PLOT PL1N INERT. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 98 HOURS IN ADVANCE <br /> SIGNED X TIT E: <br /> DATE: <br /> ACCEPTED BY TITLE: �i� .�/rn��ti_ DATE: // <br />