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• D <br /> CLOSURE OR ABAN ORHENT J\(/�� -•• <br /> IL•3' ph6neg. 468- II <br /> — _ - �� 3428 <br /> e <br /> 1PPLICITIOI fat PEIMINEIf/tIMP0IlI1 CLOSUI[ OI 1111001gI1t IN PLIC[ OF OIDIIGIOOIO 1►'IIOaOi IGIIf11CIS I}OUGI FICILITT <br /> for; PSRNit IIPIR66 10 DITS flog tot IPPROTIL DITI. DO 101 FRITt !I III S11110 IIIIS. I11[CIfE P[,I[} fiP[ IIL01: <br /> REMOVAL __ TEMPORARY CLOSURE <br /> ABANDONMENT IN PLACE <br /> F PROJECT CONTACT <br /> A PHONE f <br /> iC FACILITY NAME '` r� <br /> I h l NC ADDRESS S <br /> li L OWNER � / <br /> SjLyie �'iq ADDRESS P <br /> 11 T CROSS STREET / d Y7/ <br /> N <br /> Y PHONE f <br /> I <br /> ' O CONTRACTOR NAME !, G <br /> PHONE f ALJ <br /> I� N CONTRACTOR ADDRESS <br /> T 3 e CA LIC 1 <br /> I R LIC CLASS <br /> A C,6 / WORK. CORP.161 k <br /> INSURER <br /> T FIRE DISTRIC /�/ �. PERMIT I <br /> O LABORATORY NAME C > <br /> R \ ��i PHONE f :Z:' <br /> SAMPLERS <br /> S-G <br /> SAMPLERS NAME <br /> ( SAMPLING METHOD <br /> I C VOLUME CHEMICALS STORED DATES STORED i CHEMICALS STORED <br /> H ID q E 11 CURRENTLY PREVIOUSLY <br /> M <br /> I 0 S L TO lyb b <br /> C IZAjiTO (SJ <br /> A TO <br /> L LIS ANY EXTRA TANKS ON A SEPERATE SH ET <br /> P <br /> L S E ATTACHMENT WI H CONDITIONS) <br /> A PLAN REVIEWERS NAME <br /> N DATE /e9 2 <br /> APPLICIIT MUST PERFORM ILL FOR' IN ICCOIDIfCE FEIN Sly JOIQUII COUITT ORDIIIICES, STlff LIFS, 110 RULES JID ttCULITIOIS <br /> OF THE Sig JOAQUIN LOCIL 1IILTI DISTRICT. 01NER OR LICEISID IGEIT'S SIGIITURE CERTIFIES fit FOLLOIIIG: of CIRfI►I fB/f <br /> IN THE PERFORMIICC OF TIE FORE FOR FRICf f11S PERMIT IS ISSUED, I SEILL for INPLOT III PEtf01 it SUC1 1111CI 15 TO Itcoxg <br /> SUBJECT TO FOR'KIK'S CONPEISINOI L1fS OF CILIFORNII.• COITIACTOR'S 81111G Of SUI-011/ICT110 SICNITURE CEITIFIES fit <br /> FOLLOFING: 'I CtRTfFT T/lT (I fig PERFORNUCE OF TEE FORE FOR FIICB TIIS PERNff IS ISSUED, I STILL tKPLOT Pt1S0IS SUBJECT <br /> TO FOREKAN'S CONPINSATIOI LIFS OF CILIFORIII. CONPLETE DRIFING 01 ATTICIID PLOP PUI Sfttf. <br /> CALL FOR ALL NECESSARr INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED X0 <br /> E: DATE: O— Z <br /> ACCEPTED BY TITLE: DATE: <br />