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U-T <br /> A6 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL fiEALTH DIS RICT <br /> UNDERGROUND TANK 1601 E HAZELTON AVE. , STOCKTON CA I <br /> CLOSURE OR ABANDONMENT Telephone ( 209 ) 468-3420 <br /> 1PPLICITION FOR PRIMININWIMP0111► CLOSURE OB IBINDOMMQNT IN PLICS OF UNDERGROUND H/DIRDOUS SUBSTINCES STORAGE FACILITY <br /> THIS PIIMI YPIIES 90 D1Y1 FROM TVI 1PPIOVIL DITS. DO 10T VR1T1 IN INl SUIDID IREIS. INDICITS PERMIT TYPE BELOV: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACT PHONE # <br /> A _ <br /> I FACILITY NAME �jn/. T, <br /> -- '-- -- <br /> if7D /V�6r� ADDRESS `,e.Si!/9 } <br /> L CROSS STREET - --- PHONE # �� -- -- ._.-_�L__._.-.._.. ._.. <br /> T OWNER <br /> Y PHONE # _ 4-1,40' 3� — <br /> C CONTRACTOR NAME O / 6/�7 PHONE # Z� <br /> O <br /> N CONTRACTOR ADDRESS PPl Q cT.fi `�'LO CA LIC # -- <br /> T .5 DO <br /> R LIC CLASSWORK . COMP. <br /> A # INSURER <br /> — <br /> C FIRE DISTRICT <br /> T PERMIT # — <br /> 0 LABORATORY NAME <br /> R PHONE # <br /> SAMPLERS NAME SAMPLING METHOD V <br /> — _ ____ _ <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID # CURRENTLY <br /> E _ PREVIOUSLY <br /> M (1U0 <br /> I TO <br /> C TO <br /> A -TO- <br /> L <br /> OL LTo <br /> IS ANY EXTRA TANKS ON A SEPERATE SH -ET <br /> I � I <br /> P OWN <br /> N�A�� q yr III APMED <br /> L (SEE ATTACyME WITH NDIOTINONS) �° <br /> A PLAN REVIEWERS NAME !I< <br /> N DATE <br /> IPPLICINT MUST PERFORM ILL FORT IV 1CCORDINCI film SIN JOIQUIN COUNTY 010f11NCIS, STITI L1VS, 110 RULIS IND RICULITIONS <br /> OF THE 311 JO10UIJ LOCIL 111L?H DISTRICT. OVVER 09 LICES39D IGIIt'S SIGIITURE CEITIFIES ?HR FOLLOVING: '1 CERTIFY ?RIF <br /> 11 THS PERFOlM110E OF TNI FORK FOR FVICt THIS PERMIT is ISSUED, f 811LL NOT EMPLOY 1NY PIRS01 IN SUCH MINHEI 1S TO BECOME <br /> SURJEC? TO VORKMII'S COMPINSITI01 Las OF CILIFORNII., COI?RICTOR'S HIRING OR SUI-CONTRICTING SIGNITURE CERTIFIES THE <br /> FOLLOGIC: of CSRTIFI ?HIT IN THE PERFORM/NCE OF THE FORK FOR PRICE 11I3 PERMIT is ISSUED, I SHILL EMPLOY PERSONS SUBJECT <br /> TO FOREMEN'S COMP11317101 LITS OF CILIFORNII. COMPLETE DRIVING ON 1?TICHED PLO? PL1R #at. <br /> CALL FOR ALL N CESSARY INSPECTIONS AT CCLEAST 98 HOURS IN ADVANCE p <br /> SIGNED X TITLE: /�cS1, DATE: (/ <br /> ACCEPTED BY TITLE <br /> DATE: <br /> I V'fl.PJ''I ! i + nn l ,I ,�SCJVI'"V9V'^N,I."„nIFN s � Ertl!VVaBL'ik'VI!CCCJU�iI"�6NW"IG61iVV110L'MDD".'"i'dVIllIVVV!0'uI°1NIHHNIrNIe:'EiY'WtlINM6._4.' ':,.;tY7' w..Su9Vt <br /> i i 4/'er ua wmlr nl i n•cr.r. ...,. :,,.. <br />