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Ah <br />'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 />IPPLICITIOB FOR PERMIBEIT/TRMPORIIY CLOSURE OB IBIBDOMMIIT IM PLICE Of UBDIRCROUMD HIYIRDOUS SUBSTIICIS STORAGE FACILITY <br />TRIS PERI)IT EIPIRES 10 DIPS FROM TEE 1PPROTIL DITE. DO NOT ERITI IM 111 SIIDIB IRE1S, IEDICITI PERMIT TYPE BELOW: <br />1/ REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br />'I 1-),q <br />F <br />PROJECT CONTACT (j; j __FP <br />HONE <br />C <br />FACILITY NAME �°—+--� <br />ADDRESSLpefe �f <br />I <br />�h �� <br />1 - <br />L <br />CROSS STREET Q� <br />PHONE M7D / 3� -O� 0 <br />OWNER <br />PHONE M / <br />Y <br />� /A <br />------..._ <br />C <br />— -- --- <br />CONTRACTOR NAME S, S <br />--__-- <br />PHONE <br />0 <br />N <br />CONTRACTOR ADDRESS /' — <br />/iZo /_). GLS �V, <br />00 <br />---- --- -- <br />CA LIC 1309/0 <br />T <br />---- <br />R <br />r <br />LIC CLASS WORK. COMP. BIf),tINSURER <br />C <br />FIRE DISTRICT(: PERMIT M <br />�- <br />T <br />„C11 CJ?�^�D <br />0 <br />LABORATORY NAME <br />-- - <br />PHONE M_/ <br />R---- <br />--- -- -- - - .. <br />SAMPLERS NAME SAMPLING METHOD <br />C <br />VOLUME CHEMICALS STORED DATES STORED CHEMICALSSTORED <br />H <br />ID H CURRENTLY PREVIOUSLY <br />E- <br />I <br />-- -- -- -- -- <br />A/44C <br />rO c a O <br />j/ TO' <br />TO <br />A <br />TO <br />L <br />LIS ANY EXTRA TANKS ON A SEPER�Ay�pTE SH ET <br />ONS r' <br />P <br />L <br />(SEE $7�'T C MEN WITH CONDITIONS) <br />A <br />PLAN REVIEWERS NAME � DATE A? Z,S vj <br />N <br />1PPLICINT BUSt PERFORM ILL MORN II 1CCORDIMCE MITE SIB JOIUUIM COUNTY OIDIBIBCIS, ST1TE LIMS, IBD RULES EMD RIGULITIOMS <br />OF THE SIB JO10U11 LOCH 111011 DISTRICT. CHILE OR LICENSED 1GIIVS SIGIITURB C11/1FIES TIE FOLLOIIMG: 11 CERTIFY HIT <br />If THE PIRPORMINCI OF fit MORE FOR MMICH THIS PERMIT YS ISSUED, I SWILL BOf EMPLOY 1NY PIRSOI IB SUCH MAMMAE 1S TO BECOME <br />SUBJECT TO WORINII'S COBPIIJIT101 LEMS OF CILIFORMII.' COBTRICTOR'S BIIINC OR lUl-COMTRICTINS SIGMITURI CERTIFIES THE <br />FOLLOBIBG: 'i CERTIFf THIT It THE PERFORMANCE OF THE WHY FOR WHICH fill PERMIT IS ISSUED, I SHILL EMPLOY PERSOIS SUBJECT <br />TO WORINIB'S CONPIISITION LITS OF C1LIP0B1I1. COMPLETE DRIWIIG ON Iff1CMED PLOT PLIB SH11T. <br />CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 98 HOURS IN ADVANCE <br />SIGNED X �s��t TITLE: (( DATE: <br />ACCEPTED BY TITLE: DATE: <br />