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e <br /> �I UNDERGROUND TA[ft II 1601 E HAZELTON <br /> L CLTelephonee ( 209 ) 968-3928 <br /> OSURE OR ABANDONMENT I 8-3428ON CA <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND RALARDOUS SUBSTAICIS STORAGE FACILITY <br /> THIS PIRMIT (IRES 90 DAYS FROM THE APPROVAL DATE. DO NOT (RITE II 111 SAADID ARIAS. INDICITE PERMIT TIPS ORLON: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> r F PROJECT CONTACT <br /> PHONE N vLor l lf3.f�- 75 L>— <br /> C FACILITY NAME ADDRESS <br /> L OWNERADDRESS <br /> I'� CROSS STREET — - PHONE N <br /> I C CONTRACTOR NAME PHONE N <br /> III o �E�c1w-------_ <br /> N CONTRACTOR ADDRESS CA LIC N <br /> /1 <br /> R LIC CLASS WORK . COMP. N INSURER <br /> A <br /> C FIRE DISTRICT PERMIT N <br /> 0 LABORATORY NAME /) �T Q Lir PHONE N --?) / , —?= 4y�b <br /> SAMPLERS NAME SAMPLING METHOD <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> CURRENTLY <br /> — ID N PREVIOUSLY <br /> E <br /> I <br /> C =To <br /> — <br /> A TO <br /> L TO <br /> LIS ANY EXT A TANKS 0 ' A SEPERATE SH ET <br /> P will <br /> L (SEE ATTACHMENTWITH CONDITIONS) <br /> N PLAN REVIEWERS NAME %A>/r/ l��%�.q DATE <br /> all Jim <br /> APPLICANT MUST PERFORM ALL FORK IN 1CCORDINCB FITH SAH JOAQUIN COUNTY ORDIIINCES, STATE LAYS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL 811LfR DISTRICT. DINER OR LICENSED AGENT'S S101ITURE CERTIFIES TBR FOLLOFING: of CERTIFY ?HIT <br /> IN THE PERFORMANCE-OF THE FORK FOR PEKE THIS PERMIT IS ISSUED, I SHALL NOf EMPLOY ANY PERSON II SUCH MANNER AS TO BICONR <br /> SUBJECT TO FORKMAN'S COMPINSATION LAYS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUN-CONfRACTIIG SIGNATURE CERTIFIES THE <br /> FOLLOFING: 'I CERTIFY THAT IN THE PIRFORNANCS OF THE FORK FOR FRICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br /> TO FORKMAN'S COMPBISATION LAYS OF CALIFORNIA. COMPLSTE DRIIING 01 ATTACNID PLOT PLAN SHIST. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 98 HOURS IN ADVANCE <br /> SIGNED X TITLE: DATE: <br /> ACCEPTED BY TITLE: DATE: <br /> nnonnioimn�nnnmxmunpnnwxiauunmmx�nwn�smn�mnn�nim� wnxammiAxinnmmnammmmuim�n. �ummmooeinnnnmm� <br /> nom <br />