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UNUERUKUUNU TANK--- (l 1bUl !; HAZEL't'uN AVE. , <br /> CLOSURE OR ABANDONMENT . c:TOCK'I'uN LA <br /> Telephone ( 209 ) 9f,8-3928 <br /> IPPLICITION FOR PERMINENT/TEMPORARY CLOSURE OR IBINDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTINCES STORAGE FACILITY <br /> THIS PERMIT WIRES 90 DAYS FROM THE IPPROVIL DITE. DO NOT IRITE IN IIY SHADBD AREIS. INDICATE PERMIT TYPE BELOW: <br /> L-1-REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACT C( �Dee�� i <br /> PHONE M <br /> A Modest ..... .r .-....ZC4.._..,._-.....i......................_........ . .. <br /> ........................_........ .. ...._ ........................ <br /> C -"FACILITY NAME ADDRESS <br /> I _ Modes Mc _.................. <br /> L !OWNER <br /> ADDRESS <br /> f I _ c sQ.zz ......... ..........._....._ 5 so. YA l e s7 s. F <<�, 3y.... <br /> _- ........... <br /> i Y CROSS STREET 1,-_- <br /> PHONE Y141 <br /> ....- ...._.......... <br /> C CONTRACTOR NAME l.....I PHONE N <br /> o ► _...Thi ,c. .e...._Or..L..., ►�c.... _ .._..__..__ <br /> ..... . . ...... <br /> N I CONTRACTOR ADDRESS �5 /... •.. ..f kM_An� r2oQ� �Oc�i. ...._cA.._L..I_C... ._#.....LF15(ocl�/ <br /> T --- _.__._....___ ..___. _._ <br /> R LIC CLASS WORK . COMP . N j INSURER <br /> A �. _ ___.._....______...........__.._....__._....._........._._......._........_ . ......... .........._.............:::::::..... . .: :_�..:::, .....::... ... .. .... <br /> C FIRE DISTRICT i PERMIT N <br /> T �IA► EGA ��2c_.. n 1._...........I..... .......__.._....I , I� <br /> 0 LABORATORY NAME _ ___..._ . PHONE N �cLR N-NipIvI_E __ <br /> _..._..._.._..._. <br /> SAMPLERS qAME SAMPLING METHOD <br /> _. . <br /> ___... Y y�, ---�_._.._.._..__ i_... _ _ ___........_....._....._.._.._._ ._.........._._.._: .___.....-........._..._...._..._ ._....S.:............_:._-:._ <br /> — C� A VOLUM� CHEMICALS STORED I DATES STORED CHEMICALS TORED <br /> H ID N CURRENTLY PREVIOUSLY <br /> E I <br /> M C�UU L�1��Sl� ., TO <br /> I TO <br /> C TO—1 <br /> ATO Ii i <br /> L LIS ANY EXTRA TANKS ON A SEPERATE SHEET <br /> L (SEE AT HENT WITH,,CONDITIONS) <br /> A PLAN REVIEWERS NAME DATE <br /> -3-�� <br /> N � <br /> �� E�'��� ""I� e4 ���I�'I��� '° i�� ��'��V�� 69d������"��u�n'������'�i�r"� ���1�'uVi °����n�i��'��iai&i��l '��"•• <br /> APPLICANT MUST PERFORM ALL YORK IN ACCORDANCE WITH SIR JOAQUIN COUNTY ORDININCES, STATE LAWS, IND RULES AND REGULATIONS <br /> OF TRE SAN JOAQUIN LOCAL HEILTH DISTRICT. OWNER OR LICENSED AGENT'S SIGYITURE CERTIFIES THR FOLLOWING: 41 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE FORK FOR WHICH THIS PERMIT IS ISSUED, I SHILL NOT EMPLOY ANY PERSON IN SUCH MANNER IS TO BECOME <br /> SUBJECT TO YORIMAN'S COMPENSATION LAYS OF CILIFORNII.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: '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 LAWS OF CALIFORNIA. COMPLETE DRIVING OR ATTICBBD PLOT PLAN SHEET. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 98 HOURS IN ADVANCE <br /> SIGNED X TITLE: �� S __ _� DATE: _/-3����. <br /> ACCEPTED BV TITLE: DATE: <br /> Frill <br /> AM <br /> Mud= <br /> a�ra:xWram�a�rm��"i�Gi "mm`"�INin�• ��r,Nu"�i�i�n�un�''nX���"Ii"4mymldD��I�A�'N Www�"anu� i'I �n,��ii 67YW a '91Ui�1�{V{Ni'��QBD�WI�IRY�L7llDdllIW�IlEl9tlii�6�IWGIWWIIIVk1119�IHIYGIIWGIII'JdBgG�gll��lq <br />