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i� UNUENGRUUNU TANK l 1bUl N HA'LELTUN AVE. , STUCKTUN CA II <br /> .CLOSURE OR ABANDONMENT Telephone ( 200 ) 468- 3428 <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT jIfiIRES TO DAYS FROM THE APPROVAL DATE. DO ROT WRITE II ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACT <br /> ela, cleDejfe�� PHONE # <br /> A _ _-- --Nloraesiv Qr� TCt✓ <br /> C FACILITY NAME ADDRESS <br /> I -- ---- Moaesly Oar .a aCoC� -5. <br /> ---. _-. ..._. <br /> _. <br /> L OWNER r1 ADDRESS <br /> I _. 1 !- �e�cy ILt CASQLZ✓� J _ ._.__ 53C� WAIF ST S F 9- 113y . <br /> T j� CROSS STREET <br /> PHONE # x IJ / <br /> Y � _ _ <br /> C CONTRACTOR NAME PHONE # —)5� <br /> o --- - <br /> T CONTRACTOR ADDRESS �5 / CA LIC # <br /> � k M Fhv �oF (�P t. LFj5(Oci cl.- <br /> R LIC CLASS WORK . COMP . # INSURER <br /> -------- -- -- -- <br /> — -- <br /> C FIRE DISTRICT PERMIT # <br /> T -- - -- MAKrt�cra.. Fi2E � P II <br /> 0 LABORATORY NAME I PHONE N ZOO/ �1R3- 13� <br /> /�pp I <br /> R <br /> - 1 SAMPLERS NAME SAMPLING METHOD <br /> - <br /> C VOLUME CHEMICALS STORED I DATES STORED CHEMICALS STORED <br /> H ID # I CURRENTLY PREVIOUSLY <br /> E _.. <br /> M LOCO LJIISEL _.._... � ._ TO i . .q 2.�W2 <br /> I I TO <br /> C TO 1 — <br /> LP gg � LIS ANY EXTRA TANKS ON A SEPEOATE SH�ET �I <br /> a Illlllllu Itltl µjNyilil � �dIpiu�dl � H��ifl NJ fl10� �7NflG� I�P � ��I�IIi ��iBli7iiHiN�� <br /> it L (SEE ATS' "ENT WITH ONDITTONS) <br /> A PLAN REVIEWERS NAME C DATE3— <br /> "_._ IGII�I�h��pnPdpmn" 9N�4�N"i�xx — _ r <br /> --- I��HIMIIP 9�I�Y Ip�Nl l " q I"�I,„�u B�Px9' 149 k uH d' G� u�'JII Va9d ii ' " �k6 6"i�Hill 11111111 11 di1V�°JV NP 45,ih��8a�i�i lel <br /> APPLICANT MUST PERFORM ALL FORA IN ACCORDANCE WITH SAN JOIQUIN COUNTY ORDINANCES, STATE LAYS, AND RULES AND REGULATIONS <br /> OF THS SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES ?MR FOLLOWING: 'I CERTIFY THAT <br /> IN THS PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON R SUCH MANNER AS TO BECOME <br /> SUBJECT TO YORKMAN'S COMPENSATION LAYS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOFIMG: 'I CERTIFY THAT IN THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br /> TO WORKMAN'S COMPENSATION LAYS OF CALIFORNIA. COMPLETE DRAWING 01 ATTACKED PLOT PLAN SHEET. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED X TITLE: A9- S DATE: <br /> ACCEPTED BY TITLE: DATE: <br /> 140 Ptwf Ow" <br /> aL-72inmummimiuunimmvoxnmwunmxDXWNNxIIWiRARItlIIIN1CIWGDIlirtlnO u <br /> Mmwixm�mux119WIIgII�NRIIAMVitlNR�4p11611RWtl i INI6'EWIWIYItlNWoIIIIN6,w,WIA1L8,DWtl�IDItltlWNICDI�IIAYYYZ� tlllWWWDW9RIWYtlIIUUtlJNNR ) <br /> �„niiININ��1ltlnum��ix�n�emimin��dlw:�mm�umumixtmneimimm:nn� nmxpxmuiimnx:-.i ia�mnmmxrximinnoninut.xmoao,mnmimmn,.,i„imnmoammieNnx <br />