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iL11111113 OR ABANDONM'EIT Telephone ( 20 ) 968-3928v �n <br /> APPLICATION FO PERMANEIT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE Of UNDEAGAOVAD IAEIRDOUS 9989T1106E iTD11G6 IICILITY <br /> THIS PERK IPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT IRDS II 111 SHIDID AREAS. IIDICITI PSINIT TIPS ISL01: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACT PHONE # .t2 <br /> A <br /> C FACILITY NAME ADDRESS <br /> I — <br /> OWNER — ADDRESS <br /> II T CROSS STREET PHONE # <br /> Y _ <br /> C CONTRACTOR NAME QP������ S�',f�— S �/ /�(oZ <br /> 0 PHONE # <br /> N CONTRACTOR ADDRESS CA LIC # <br /> T46 <br /> R LIC CLASS WORK. COMP. # <br /> A INSURER <br /> _ <br /> C FIRE DISTRICT PERMIT # <br /> T -- —-- <br /> 0 LABORATORY NAME PHONE # <br /> R <br /> SAMPLERS NAME SAMPLING METHOD <br /> If C VOLUME t CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID N CURRENTLY PREVIOUSLY <br /> IE — ------ _. <br /> M L. /�tJr [ Unk TO <br /> I TO <br /> C -TO- <br /> A TO <br /> L LIS ANY EXTRA TANKS ON A SEPERATE SH ET <br /> P <br /> L (SEE ATTACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME �n7lw-- llc'.9v�64_ DATE �J <br /> —N <br /> APPLICANT MUST PERFORM ILL FORK IN ICCOROINCE FITH SAN JOAQUIN COUNTY ORDINANCES, STATE LIFS, AND RULES IND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. DINER OR LICENSED AGE111S SIGIITURS CERTIFIES TAR FOLLOIIIG: 'I CERTIFY THAT <br /> IN TRS PERFORMINCS'OF TRS FORK FOR IRICI THIS PERMIT IS ISSUED, I SHILL NOT EMPLOY /NY PERSON II SUCK 1111161 IS TO BSCONS <br /> SUBJECT TO FORKMAN'S COMPENSATION LITS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-COITRACNIG SIGIITURS CIRTIFISS TRS <br /> FOLLOFING: 'I CERTIPY THAT IN THE PERFORMANCE OF In FORK FOR FRICH THIS PERMIT IS ISSUED, I SNILL SMPLOT PERSONS SUBJICT <br /> TO FORKMAN'S COMPENSATION LAIS OF CALIFORNIA. COMPLETE DRAPING 01 27TICIEO PLOT PLAN SHEST. <br /> CALL FOR LL NECRPSARY INSPECTIONS AT LEAST 98 HOURS IN ADVANCE <br /> SIGNED X TITLE: L DATE: / 2 <br /> ACCEPTED B TITLE: DATE <br /> CIIBWIAIAIRi9NRAgAXMGeIIYlIWM1AAAY1lWMNIPiFIWMWMMWM1AR11NW14WWNNWdWIIYiRMMil1dAA1MMIXIWAIXAGHtlIRiMY11AAA'gAAAWAI'ilI11Wl1io1PSCARA@I�IW WAAIOIRYWII�RAPIIII <br /> y.. <br />