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—e+P?LIGATION FOR PERM.. , — <br /> SAN JOAQUIN LOCAL ALTO DISTRICT <br /> UNI►ERGROUND TANK 1601 E HAZELTON AVE. , STOCKTON CA <br /> LCLOSURE OR ABANDONMENT -- —Telephone—( 209 ) 468-3420 <br /> APPLICATION FOR PERMINENT/1EMPOR111 CLOSURE OR ABANDONMENT IM PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PES T EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT RRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELON: <br /> V REMOVAL TEMPORARY CLOSURE <br /> I� ABANDONMENT IN PLACE <br /> F PROJECT CONTACT � <br /> Gnzvl t —1 PHONE # / 411 -lCq`f - <br /> A ---- <br /> C FACILITY NAME ' - ADDRESS Z14 S Sum <br /> }QJ .YvoCYJR --...-------------........------.................... <br /> L CROSS STREET WW� o- PHONE #_J <br /> T OWNER t" I 1 PHONE # / 444' 9 <br /> Y ( 0j ST FA� -�uIDUcVJdv�CS wO Azc,h.OL) <br /> C CONTRACTOR NAME�LJI­ v„'',,,, C/cCOI PHONE # <br /> N CONTRACTOR ADDRESsp'o � 9S1ao — CA LIC #L0 z-77_A <br /> Ti -- ---- - - -- .. <br /> R LIC CLASS WORK . COMP . # INSURER <br /> C FIRE DISTRICT ( — Dr S �L�,rPERMIT # <br /> T =J- ---( --� ---- - <br /> 0 LABORATORY NAME <br /> R PHONE # 91� <br /> VLew, v �1s,o <br /> SAMPLERS NAME SAMPLING METHOD <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID # CURRENTLY PREVIOUSLY <br /> M C 1Sa�l a� tinf2nowv�- �� --- TO --- <br /> I TO <br /> C TO <br /> A TO <br /> L LIS ANY EXTRA TANKS ON A SEPERATE SH ET <br /> P r <br /> L (SEE T MEN <br /> WITH CONDITIONS) <br /> A <br /> PL ::R REVIEWERS NAME _ DATE <br /> N <br /> APPLICANT MUST PERFORM ILL FORK IN ACCORDANCE WITH SAN JOIUUIH COUNTY ORDINANCES, Sf1TE LAWS, AND RULES AND REGULATIONS <br /> OF THE SIN JOlOUIN LOCAL BEILTH DISTRICT. OWNER OR LICENSED 1G11T'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF TEE VORC FOR VOICE THIS PERMIT IS ISSUED, I BRILL HOT EMPLOY ABY PERSON IN SUCH MINNER is TO BECOME <br /> SUBJECT TO 1011MIN'S COMPENSATION LAWS OF CILIF01111.' CONTIICTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY TBIT IN THE PERFORM/NCE OF THE FORK FOR VOICE THIS PERMIT IS ISSUED, I SHILL EMPLOY PERSONS SUBJECT <br /> TO FORKMIN'S COMPENSATION LAWS OF CALIFORNIA. COMPLETE DRIVING ON 111ICHED PLOT PLAN SHEEP, <br /> CALL FOR ALL NECESSARY INSPECTIONS AT L( .I <br /> EAST48 HOURS IN ADVANCE <br /> SIGNED N �� <br /> TITLE. < ✓ \J. It II, DATE: I0'LB•68 <br /> ACCEPTED BY TITLE: > DATE:r IFT E I s PER <br />