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APPLICATION FOR PE SAN SAN JOAQUIN LOCA�IEALTH DISTRICT <br /> UNDERGROUND TANK 1601 E HAZELTON AVE. , STOCKTON CA <br /> CLOSURE OR ABANDONMENT Telephone ( 209 ) 968-3920 <br /> IPPLIC1T10N FOR PEIMANEIT/tEMPORIIY CLOSURE OR IBINDONMIIT IN PLACE OF UNDERGROUND 91111DOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM TRE APPROVAL DATE. DO NOT WRITE IN 111 SMIDID AREIS. 1NDICITE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACT 5 for /yf f Z PHONE # I/6 / G �)a 302/ <br /> A <br /> C FACILITY NAME -5 K J/vADDRESS <br /> L CROSS STREET PHONE 0---/ <br /> T OWNER PHONE # / <br /> Y x <br /> C CONTRACTOR NAME //7/ N os 0m p, PHONE <br /> 0 ---- <br /> N CONTRACTOR ADDRESS CA LIC # 3// 76 <br /> R LIC CLASS 3 G2 WORK . COMP . # — INSURER,// /j M_f�gr <br /> A — -_ ----_ r _— ... <br /> C FIRE DISTRICT —LPERMIT # <br /> 0 LABORATORY NAME` - PHONE # <br /> R <br /> SAMPLERS NAME SAMPLING METHOD <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID # CURRENTLY PREVIOUSLY <br /> M I j- 1 '-1 y J^�� (,[.��.P1 e"�9-c ilk, �'lin, .-'�T 0 •_..fi,�.n-w_., <br /> I J �TO <br /> C TO <br /> A TO <br /> L LIS ANY EXTRA TANKS ON A SEPERATE SH ET <br /> pl .I I � � <br /> i � <br /> P <br /> L (SEE A TT ENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME � a�,I i DATE <br /> N— <br /> IS i �I� B i i ' ��, i. <br /> APPLICANT MUST PERFORM ILL WORK IN 1CCORDINCE FIt# SAI JOAQUIN COUNTY ORDIIINC/S, STATE LAWS, AND RULES AND REGULITIONS <br /> OP THE AAI JOIBUII LOCAL BEILTR DISTRICT. OWNER OR LICENSED 19IIT'I SIGIITURR CERTIFIES TBH FOLLOIIBG: 'I CIITIFT TWIT <br /> IN THE PERFORMIICB OP TRE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHILL NOT EMPLOY III PERSON 1► SUCH MINNER IS TO BECOME <br /> SUBJECT TO WORINII'S COMPIIIITI01 LABS OF CILIF011I1.' COINICTOR'S HIIING OR IUI-CONTRICTING SIGN17URE CEITIFIES THE <br /> POLLOYIIG: 11 CERTIFY THAT If TME PRRFORMIICI OF THI WORK FOR WIICH THIS PERMIT IS ISSUED, I SE/LL EMPLOY PRRSOIS SUBJECT <br /> TO WORKMAN'S COMPIISITI01 LAWS OF CILIFORIIA. CONPLITR D1IIIIG OH ATTACHED PLOT PL11 SHIRT. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 98 HOURS IN ADVANCE <br /> SIGNED X is >! /41- TITLE: DATE: <br /> l) /, r r <br /> ACCEPTED BY �n cif TITLE: ?t DATE: <br /> mI, HCEUA�'JH�81RIdQIU1WIANi161�BNW�1�110'NIfL'IIIKR116iJ' 1�i�CnH@91I IDIVG�CiRYi°ridi17G"wiAGBI�RMJIINIVL'6C!9_ <br />