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l� UNDERGROUND TANK 1601 E HAZELTON AVE. STOCKTON CA <br /> CLOSURE OR ABANDONMENT Telephone ( 209 ) 468-3420 <br /> J <br /> q 49S-YM-I <br /> APPLICATION FOR PERMINEITITIMPOIAIT CLOSURE OR IBIIDONMINT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS ERNIT EXPIRES TD DAYS FROM THE IPPROTAL DATE. DO HOT TRITE II 111 BENNO AREIS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACTPHONE # / `- Wo-[C34 <br /> A <br /> C FACILITY NAME rF GADDRESS I� c _ <br /> I — <br /> L CROSS STREET PHONE # / <br /> T OWNER PHONE # <br /> Y CA rq = S desWALT- ULtka-e-' <br /> C CONTRACTOR NAME PHONE <br /> LL PHONE # <br /> 0 v <br /> N CONTRACTOR ADDRESS �� [ CA LIC # Z <br /> q T <br /> R LIC CLASS2! WORK . COMP . # INSURER <br /> A lJ <br /> C FIRE DISTRICT ��GC��YL PERMIT <br /> T <br /> 0 LABORATORY NAME PHONE <br /> HER SSO PHONE # �I/� X - /70/ <br /> R <br /> SAMPLERS NAME SAMPLING METHOD <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID # CURRENTLY PREVIOUSLY <br /> M f C D17D �.t,IJKIJOwQ-C PTY TO U�KIJBWfJ <br /> I TO <br /> C TO <br /> A TO <br /> L LISt ANY EXTRA TANKS ON A SEPERATE SH ET <br /> LIN (SE ATTA E T WITH CONDITIONS) tj PLAN REVIEWERS NAME --f 411 DATE <br /> APPLICANT MUST PERFORM ILL FORK IN ICCORDINCE WITH SAN JOIQUIN COUNTY ORDINANCES, STATE Lips, AND RULES AND REGULATIONS <br /> OF THE SIN JOIOUII LOCIL IEILTH DISTRICT. OWNER OR LICENSED IG117'S SIGNITORE CERTIFIES TER FOLLOWING: 21 CERTIFY THIT <br /> IN THE PERFORMANCE OF TRE FORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY III PEISOR 11 SUCH MANNER IS TO BECOME <br /> SUBJECT TO FORIMIN'S CONPEISITIOI LITS OF C1LIP01111.' CONTRACTOR'S HIRING OR SON-CONVICTING SIGIITURE CERTIFIES TRE <br /> FOLLOWIIG: 'I CERTIFY THAT 11 TRE PERFORMANCE OF THE FORK FOR FKICH THIS PERMIT IS ISSUED, I SHILL EMPLOY PRRSOIS SUBJECT <br /> TO FOREMAN'S COMPENSATION LAWS OF CILIFORIII. COMPLETE DRIFIIG ON 1TTICNRD PLOT PLIN SHEET. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED Xu �VV Q i TITLE:4 �«n'( V, I (--(V' ✓ DATE: (G Ll \j _ <br /> ACCEPTED BY �` L r;`Zr. _ — TITLE:�I���i DATE:�� <br />