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TPS Pj r� <br /> --- ' <br /> PAP-PLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> `JNDERGROUND TANK 1601 E HAZELTON AVE. , STOCKTON CA <br /> CLOSURE OR ABANDONMENT Telephone ( 209 ) 468-3420 —� <br /> IPPLI�ITIOY R PBRXINIIT/1EMPOR11Y CLOSURE OR 111NDONXINT 11 PLACE OF UNDERGROUND YIIIIDOUS SUBSTANCES STOIIGE FACILITY <br /> THIS PER HIRES 10 DAYS FROM TAE APPROVAL DATE, DO NOT YIITI 11 11I SHIDID AREAS. INDICATE PIRXIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACT AI 8 PHONE X / <br /> Ac O/' �L(/n/ — <br /> C FACILITY NAME G� �` , g D ADDRESS <br /> I ! (i <br /> L CROSS STREET �+�rzkZ� PHONE M / <br /> I —. <br /> Y11OWNER 'Q jC � l 12,40 PHONE M <br /> C CONTRACTOR NAME �G15/a IJ `� PHONE X ��9/ y�2 —q_9 <br /> 0 <br /> N CONTRACTOR ADDRESS I67 <br /> %�S/ff;� CA LIC R <br /> T L�� 7Z� <br /> / <br /> I R LIC CLASS WORK . COMP . N INSURER <br /> A ----- —- — — - --- - <br /> C FIRE DISTRICT PERMIT M S <br /> T <br /> 0 LABORATORY NAME � LR PHO� � G�' o ISuo> <br /> R ,9 n�Al SIs -- -- <br /> SAI4PLERS NAME SAMPLING METHOD --� <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID M CURRENTLY PREVIOUSLY <br /> Mj �-/� C� S TO <br /> v lv I Yc �� 1°�iI1� To <br /> C —TO— <br /> A TO <br /> L LIS ANYE TRA TANKS ON A SEPERATE SH ET <br /> I mI r 1911Jr'IvIIli41i ! I. V4 ' J ' ryrygnl, <br /> P ! iNuu V � ?E � uWW <br /> A <br /> (SEE <br /> �nC ENT WI�Jf C NDITIO�(S) <br /> PLAN REVIEWERS NAME <br /> �< rti y DATE �O•-vr7����� <br /> N <br /> .r I 'I ' I i�g16�R4i��l�.aal6rl�l"�II�IIq�Ra�gINNIm�k�;R116��I�i�IIBI�"�"911"I�IP�a�till�fl'�I6��li�4aLYkNiti911k�a1(ko�IliRll����'16R�IEa'InlnNh'�R '! I II�I I <br /> APPLICANT MUST PERFORM ALL FORT IM 1CCOROINCE FITE SAY JOIOUII COUNTY ORDINANCES, STIFF L1VS, IID RULES AND RRCULITIOYS <br /> OF THE SAN JOAQUIN LOCAL RIILTU DISTRICT. 091E1 OR LICENSED 1G11113 SIGNATURE CERTIFIES TUB FOLLOWING: 'I C1ITIFY THAT <br /> IN THE PIRFO1NlICE OF TUI VORI FOR VVICI TRIS PERMIT IS ISSUED, I SMALL 907' IMPLOr ANY PERSON IN SUCH XIMMER 1S t0 BRCOXE <br /> SUBJECT TO VORIXIY'S CONPINSINOW LIES OF CILIFO1N11.' COITRICTOR'S WRING 01 SU1-COMIR1CTIRC SICNITUPI CERTIFIES THE <br /> FOLLOWING: 'I CERfIFT f)lf IF TME PIRFOIXIYCI OF TUI Rut FOR V11CI THIS PERMIT IS ISSUED, I SHILL IXPLOY PERSOSS SUBJECT <br /> TO VORIMIN'S COXPINSITIOI 1,113 OF CILIFORYII. COMPLIN DRIVING ON 1rT1CIIED PLOT PLAN SHEET. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED X L / — TITLE: DATE: <br /> ACCEPTED BY TITLE : DATE: <br /> n �" V Ytl M i A AVM eM •re'JA4•�.,'n1 VrMt <br /> V7HPI' f 7Y""._r nuF&W "�';'.IC !JL'Tu7YL;WyILI"O,7,p f',8."I%"'IYPIIJ�:1i'Cl!CICS`J"rJ15J,N�GN6'BJaR,V!�ICUUItl2L';M"JIIYMIt.L,�i,'LOIYO. S_i..._`.3 .;.�.u.,'LL'N'M..�...+.::C,rV- �� <br /> in <br />