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aw <br /> UVUb:i';uKuUNU 'TANK I� IbUl. E HALELTON AVE. , STOCKTUN CA I� <br /> CLQSURE OR ABANDONMENT Telephone ( 209 ) 468-34213 <br /> IPPLICITIOK FOR PERMIKETT/TEMPORIRT CLOSURE OR IBIKOOKMSRT IR PLACE OF UNDERGROUND RAIARDOUS SM111CF1 STORAGE FACILITT <br /> TRIS PERM FIRES 10 'OATS FROM THE APPROVAL BITE. -DO NOT IRATE 11 1111 S111ID IREIS. ITDICITT PERMIT TYPE BELOT: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> --____--�--��____��.—�_�--_:_-Yom.--=_:: ___- _-�:•�:�____- __:-.--- - .. . : �. -- _ <br /> F � PROJECT CONTACT j ----=--.- <br /> Ai[/4 .`/ /,rPHONE . K <br /> C FACILITY' NAME IJ !�"__ <br /> ADDRESS <br /> 411 r#420- <br /> L OWNER <br /> �I �+ ADDRESS <br /> I _ _. ..._ _....._. - __. _.._.... ..........-._.._ <br /> Tj CROSS STREET I PHONE 9 ,202 <br /> C CONTRACTOR NAME ( � / PHONE N 2G 7/ _-52f/—_ 16.53 <br /> N CONTRACTOR ADDRESS �/i - / f/ /,r ,/� CA_LIC <br /> K.fI'/pp6, <br /> R -LIC CLASSWORK . <br /> J.f I� WORK . COMP . It INSURER <br /> A <br /> C FIRE -DISTRICT 1 PERMIT D <br /> T <br /> O LABORATORY NAMEPHONE N IDS/ <br /> SAMPLERS NAME SAMPLING METHOD <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID R CURRENTLY PREVIOUSLY <br /> E <br /> M <br /> I i To I <br /> C �— I TU <br /> A TO <br /> L LIST ANY EXTRA TANKS ON-i SEPERATE SHEET <br /> PRMM!To AV ',UNDITION <br /> - <br /> �! L (SEE ATTACHMENT WITH CONDITIONS) <br /> P A PLAN REVIEWERS NAME �4'�1j ,SDATE <br /> N <br /> il N__ <br /> APPLICANT MUST PERFORM ILL FORK IN 1CCOR0ANCE PITH SIN JOIQUIN COUFTY ORDIIINCES, STATE LIPS, 1TD RULES AND RECULITIORS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OPMER OR LICENSED AGEWT'S SIGNITURF CEITIFIES TNR FOLLOIING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE FORK FOR FHICB THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MINNER Is TO BECOME <br /> SUBJECT TO FORIMIN'S COMPENSATION LAWS OF CILIFORMII.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE FORK FOR FOICH THIS PERMIT IS ISSUED, I SHILL EMPLOY PERSONS SUBJECT <br /> TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. COMPLETE ORATING OI ATTACIED PLOT PLAN SHEET. <br /> CALL FAVALL NECEfiPTARY LNSPEcTiONS AT LEAST 98 HOURS IN ADVANCE <br /> SIGNED X TITLE: DATE: <br /> ACCEPTED _ TITLE• <br /> FE <br /> Q <br /> r I - <br /> . f <br />