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' � � 1' <br /> �LO a1JfiE OR ABANDONME:F� 34 2H <br /> IPPLICATION FOR PERMANEATITENPORART CLOSURE OR ABANDONMEIT IN PLACE OF UNDERGROUND:RAIAn",M 086TANCES STORAGE FACILITY <br /> THIS PERM[ EIPIRES 10 DAYS FROM THE APPROVAL DATE. 00 NOT H ITE IN 11Y SHADED AREAS. 1101CITS PERMIT TYPE SELOV: <br /> --jeo," REM(-)'.'AL TEMPORARY CLOSURE _ ABANDONMENT IN PLACE <br /> I1: PROJECT CON;TACT � PHONE R <br /> C FACILITY NAME ADDRESS <br /> I <br /> I -a�c. .Ru {.._ s-i t-_StaN ..__.._..... . Z24?4 <br /> ,i L ; OWNER -- ADDRESS <br /> I j# .. _ Jepo-C 2at.._ �=��2�..�DLst�c-�C� _ .... . _. . Po <br /> ;I T i�CROSS STREET 101- <br /> PHONE qG� •� <br /> C CONTRACTOR NAME PHONE <br /> T CONTRACTOR ADDRESS CA LIC If <br /> R LIC CLASS WORK . COMP . M ENSURER. <br /> A:. n <br /> FIRE DISTRICT T2qc ..Rv2 � �;7ta - `S�rt F£r"E�9I3` q <br /> i <br /> 0 LABORATORY NAME PHONE M Ut.N_g83 — ►3�4Q <br /> 1 SAMPLERS NAME SAMPLING METHOD <br /> C « VOLUME CHEMICALS STORED , DATES STOREY? ' CHEMICALS STORED ~ <br /> i� H ID 0 CURRENTLY = PREVIOUSLY - <br /> �I <br /> E <br /> M me✓_ LM FJ TO p6e { <br /> 1 I i TO <br /> C TO <br /> A TO <br /> L LIS ANY EXTRA TANKS ON A SEPERATE SHEET <br /> P WITH CONDI. <br /> i€ L (SEE ATTACHMENT WITH CONDITIONS ) <br /> A PLAN REVIEWERS NAME '0,f PAC _—PA yl U+ <br /> _ ��ATlr ���C/6b� <br /> i <br /> BMW <br /> hg Ii@7� su iml <br /> APPLICANT MUST PERFORM ALL WORK IN ICCOROANCE WITH SIR JOAQUIN COYIITT ORDIIANCES, STATE I,AYS„ AND RULES AMD REGULATIONS <br /> OF THE SAM JOAQUIM LOCAL HEALTH DISTRICT. OTHER OR LICENSED AGEIT'S SIGIATURS CERTIFTES 1:0. MLLOVING: 'I CERTIFY MAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY AMI r££1;Iw FN SUCH MANNER AS TO BECOME <br /> SUBJECT TO FOREMAN'S CONPERSATION LAWS OF CALIFORNIA.' CONTRACTOR'S SIRING 09 SUB-COS, NIX SIGRATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE YORK FOR VVIC8 TRIS PERMIT IS ISSM. 1 9ILL EMPLOY PERSONS SUBJECT <br /> TO WORKMAN'S COMPENSATION LAYS OF CALIFORNIA. COMPLETE DRAWING DI ATTACIED PLOT PLAT :l£I- <br /> CALL FCS LL NEC SA .Y INSPECTIONS AT LEAST 16 Hf;k Si-- IN ADVANCE <br /> SIGNED X TITLE : DATE: <br /> ACCEPTED B ! U 4. TITLE: DATE: Z� <br /> i <br /> _ ', <br />