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IIUNDERGROUND TANK II 1601 E HAZELTON t . � STOCKTON CA II <br /> CLOSURE OR ABANDONMENT II Telephone ( 209) 468-3428 II <br /> APPLICATION FOR PERMANEIT/1EMPDRIRY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT 8 REE 10 DAYS FROM THE IPPROTIL DATE. DO NOT IIITS II 111 SHIIID IRBIS. IIDICITR PERMIT TYPE BEL01: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> I� A A /PROJECT CONTACT \ all S .1 PHONE # � <br /> C FACILITY NAME I LV2�0.Ce Irc�nS ( S�, ADDRESSa333 C 2 Cz +( <br /> I — <br /> I' L OWNER ADDRESS <br /> I vU JUfl(J iJ N a 6w .s G <br /> T CROSS STREET PHONE # W / F — 33C7-7 <br /> y <br /> OC CONTRACTOR NAME�I I Q PHONE # �/ <br /> N CONTRACTOR ADDRESS CA LIC # <br /> T _ C) a �5 l r �IS24 CFI- 9��3� 0rsr CD <br /> R LIC CLASSi �_- WORK . COMP . # a &core--i2k• INSURER TEni <br /> A — _ <br /> C FIRE DISTRICT /e 1, )NeDoo PERMIT # <br /> T �RG _ <br /> 0 LABORATORY NAMEPHONE # <br /> R — <br /> SAMPLERS NAME SAMPLING METHOD <br /> C ' lKwu VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> HID # CURRENTLY PREVPOUSLY <br /> M 1 )' 000 I G y'� CA&- TO <br /> I —TO— <br /> C TO <br /> A TO <br /> L LIS ANY EXTRA TANKS ON A SEPERATE SH ET <br /> P IN h '1i <br /> L (SEE ATTACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME DATE F <br /> N f�P�RpIB <br /> I Y NINIRNNIII1 I 011 11 <br /> APPLICINT MUST PERFORM ILL YORK IN ACCORDANCE PITH SAN JOAQUIN COUNTY ORDINANCES, STATE LIPS, IND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCIL SEILTH DISTRICT. OINER OR LICENSED AGENT'S SIGIITURE CERTIFIES TBR FOLLOIING: 11 CERTIFY THAT <br /> IN THS PERFORMINCE'OF TRE YORK FOR IH[CB THIS PERMIT IS ISSUED, I SHILL HOT EMPLOY ANY PERSON IN SUCH NINWER IS TO BECOME <br /> SUBJECT TO YORKMAN'S COMPENSATION LATS OF CALIFORNIA." COITRACTOR'S AIRING OB SUB-CONHICNIG SIGNITURE CERTIFIES THE <br /> FOLLOYING: 11 CERTIFY THAT IN THE PERFORMANCE OF THE FORK FOR YRICB THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PIRSOIS SUBJECT <br /> TO FORKMAN'S COMPENSATION LIFS OF CALIFORNII. COMPLETE DRIIING O/ ITTICIID PLOT PLIN SHEET. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED X TITLE: DATE: <br /> ACCEPTED BY TITLE: DATE: <br /> tlG19HUVIIIMDtlZu�HCtlHZtltlZ01I�M@HtlB8V�l01dpBNIN1111911�99REFAl!7Jtl@IIN�&OV9tlI�umNuulI7HYGEMIN1HRItlIHHiEI <br /> 111PAlIIIIII1111A0tlI0RIHIIIOYtlIIIIIIAIIIYIIIIIIIpIIIAINI111011111111WAIfJWIIIIN011111@IIIIOOIiIOtl'IIlAIM01A0{;OIfdIAMB�"ip V ILIIXLIIIJ111NV01Nltllbll'NAL401:MIiIl01i001PUI111R1NPYNfIMIMMYiJtlAOAIAiIl0111dYA�AINII40IIn:pLPOP7AFMm01f AlIT 'MII'AIL413lOOIfd�15PiIlA,'NOINAMIpINi6 <br />