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APPLICATION FOR PERAIT SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND TANK 1601 E HAZELTON AVE. , STOCKTO14 CA <br /> CLOSURE OR ABANDONMENT Telephone ( 209 ) 968-3920 <br /> APPLICATION FOR PIRMIJUT/TIMPURIIf CLOSURE OR 18110018911 11 PLICA OF UNDERGROUND H1111DOUS SUBSTANCES STORAGE FACILITY <br /> THIS PIRNI IPIRRS 90 DAYS FROM TNI IPPROVIL DATE. DO NOT WRITE 11 111 SHIDID IREIS. INDICATE PERMIT TYPE BILOV: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACT �Yck PHONE # <br /> A <br /> C FACILITY NAMESTEPHENS `IINCHOC� CE ADDRESS <br /> I - <br /> L CROSS STREET PHONE # / <br /> I — <br /> TOWNER ( PHONE # / <br /> Y S �PN_(_�5 ICI(OP/�C E <br /> C CONTRACTOR NAME NCST (2�7 / � L PHONE # L021 -Cola' <br /> 0 <br /> w N CONTRACTOR ADDRESS \ CA LIC IN <br /> T ���✓ T�� 2 J2i vel F <br /> R LIC CLASSWORK . COMP . # CNIP0409a14 INSURER 1511 (hS <br /> A -' -_�R P�ReS• �a-� <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 LABORATORY NAMECSL SUPT PHONE # / <br /> R — — <br /> SAMPLERS NAME SAMPLING METHOD <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> I H ID # CURRENTLY PREVIOUSLY <br /> E -- <br /> M `FODDCOL ESE 0 TO <br /> I l�A�i i tic- 7 TO C� <br /> C 3 o Gk l' s�ii n�E— ��TO !ld- <br /> A TO <br /> L LIS ANY EXTRA TANKS ON A SEPERATE SHEET <br /> a . !' <br /> P <br /> L (SE HMETWI <br /> NTH CONDITIONS) <br /> A PLAN REVIEWERS NAME H ti DATE <br /> N <br /> I <br /> APPLICANT MUST PERFORM ILL FOR 11 1CCORDIYCR WITH SIN JOlOUIY COUNTY ORDIYIYCES, Stiff L1VS, IID RULES IND REGULITIOYS <br /> OF THE 311 JOIDUII LOCAL RIALTO DISTRICT. OWNER OR LICENSED 1GIIT'S SIGIITURH CI TRI FOLLOWING: '1 CERTIFY ?HIT <br /> IY THE PIRFORM/ICI OP THE IORS FOR WNICY tH13 PIRMIT IS ISSUED, I SWILL 101 EMPLOY ANY PERSON 11 SUCH MIHHER is t0 BECOME <br /> SUBJECT TO WORLMI1.11 COMPIYSITION LAWS OF CILIF02111.' COYTRICTOR'S HIRING OR SUI-CON?RICflYG SIGNATURE CERTIFIES THI <br /> FOLLOWING: of CER?fFf ?HIT IN THE PIRFOINIYCE OF THI WORK FOR WENCH THIS PERMIT IS ISSUED, I SHILL EMPLOY PERSONS SUBJECT <br /> TO WORIM/N'S COMPI131TIOI LAWS OF CILIPORYII. COMPLETE DRIVING ON lT?ACHED PLOT PLAY 3HRET. ,r � <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 98 HOURS IN ADVANE ' <br /> SIGNED X TITLE•_ DATE: r ' <br /> ACCEPTED BY TITLE• DATE: // Y <br /> . � .. <br /> � �WBYFxueMM•.at�NkwM+:,�ARTmlry.t.7��^M,t^16^C.�rvp ••+l:.kn"6LQNA� lutl�^N�Crn <br />