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APPLICATION FOR PERM SAN JOAQUIN LOCALALTH DISTRICT <br /> UNDERGROUND TANK 1601 E HAZELTON AVE. , STOCKTON CA <br /> CLOSURE OR ABANDONMENT Telephone ( 209 ) 468-3420 <br /> IPPLICITION FOR PERMINSIT/TIMPOR►RT CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DIPS FROM THE IPPRO/AL 1117E. DO NOT WRITS IN IMI SHADED ARSIS. INDICITS PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACTS PHONE # / <br /> A I)GZM 2-0q/( QPim a/1 -- <br /> C FACILITY NAME MCutika �� ADDRESS <br /> I _ `fin,,: ,;�„4 — __...-------•- 134 S _S�-(�x.��-�__.___---- <br /> L CROSS STREET „ ! PHONE — <br /> I w <br /> T OWNER PHONE # <br /> C CONTRACTOR NAME I'll PHONE # —� <br /> p ----- <br /> N CONTRACTOR ADDRESS "'0 3®>c CA L I C <br /> R LIC CLASS 3 WORK . COMP . # INSURER <br /> A -- <br /> C FIRE DISTRICT COS PERMIT # <br /> T 1/ =t0, ---- <br /> 0 LABORATORY NAME PHONE <br /> �1 i�1FLZl�uy- — # / <br /> SAMPLERS NAME -- SAMPLING METHOD <br /> C- VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID # CURRENTLY PREVIOUSLY <br /> E ------ - --- -, ------ - -...._._ <br /> M u fd)(d,SEklf ) A ©i I <br /> e TO <br /> I <br /> —TO— <br /> C —TO— <br /> A TO <br /> L LIS ANY EXTRA TANKS ON A SEPERATE SHIkiT <br /> H1111111w am SEWNQ <br /> P <br /> AF <br /> L (SEE ATTACHMEH CONDITIONS) <br /> A PLAN REVIEWERS NAME DATE /a u <br /> IPPLICIKY MUST PERFORM ALL EORl IN ACCORDANCE WITH Sly JOAOUIN COUNTY ORO[YINCES, STITE LITS, AND RULES AND REGULATIONS <br /> OF THE SIN JOIDUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED IGINT'S SIGNITURR CERTIFIES TRR FOLLOWING: Of CERTIFY THAT <br /> 11 THE PERFORM/NCE OF TNS TORR FOR 1HICH THIS PERMIT IS ISSUED, I SHILL NOT EMPLOY INY PERSON IN SUCH MIMNEI IS TO BRCOMR <br /> SUBJECT TO WORIMIN'S COMPENSATION LITS OF CILIFORMII., CONTRICTOR'S HIRING OR 101-CONTIICTING SIGN/TURF CERTIFIES THE <br /> FOLLOYING: 'I CERTIFY THAT I1 THE PERFORMINCE OF THE WORK FOR WHICH T11S PERMIT IS ISSUED, I SHALL EMPLOY PERSOIS SUBJECT <br /> TO WORKMAN'S COMPENSITI01 LIES OF CILIFOR111. COMPLETE DRIFIIG ON ITTICHED PLOT PLAN SHEET. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED X �y TITLE: DATE: <br /> ACCEPTED BY &rY, TI TLE:��n Saa/Yv DATE: <br /> IRN".0 <br /> II V ''''uIi�Vll�'i!i&IPd!w�:L211JL�N�.RNIgU1�Jl"ov"tlMPi!!I'ICI.V'dpaW�I141n1WIBiaiNIiBIINI!Neu".N4'l�'IWi191YIFd911N!RIIiNiI81VNMI�MMI11dIi!1!NJI04uw'll'.�IBaei WwivWll' 'In <br />