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UNUEi<UhuUNU TANKS �I 16U1 E HA'LELTUN AVY;., STL)CKTUN CA II <br />CLOSURE OR ABANDONMENT Telephone (209) 468-3428 <br />APPLICATION FOR PERMINEIT/TEMPORIRT CLOSURE OR IBAIDONNSIT IN PLACE OF UNDERGROUND HAZARDOUS SUEITIBCBS STORAGE FACILITY <br />THIS PERMIT PIRBS 10 DAYS FROM THE APPROVAL DATE, DO NOT WRITE II ANY SHAPED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br />F PROJECT CONTACThk <br />PHONE q 209/ 52 1 4053 <br />C FACILITY NAME ADDRESS <br />I ... I75`rj7. S �.SAI�/�Qf r~ <br />L OWNER ADDRESS <br />I /75 7 s. _Etc lax 13Yel'kt, <br />T I CROSS STREET PHONE R .zoi/ X39 3326 <br />Y��-..._.___. ....._..__— _.._... <br />C CONTRACTOR NAME T PHONE q Z�y / 5zc/ rj(oS3 <br />T I CONTRACTOR ADDRESS r N_/h Q 1 Al, + CA LIC <br />TTCC --- <br />R LIC CLASS WORK. COMP. 4 INSURER <br />C FIRE DISTRICT PERMIT q <br />T—. _ — .. _ _ .. 4 <br />0 LABORATORY NAME I PHONE N_/_SZ]-Z/OSO <br />R --.. <br />SAMPLERS NAME SAMPLING METHOD <br />-- -__ <br />CP <br />VOLUME CHEMICALS STORED I DATES STORED CHEMICALS STORED <br />H CURRENTLY PREVIOUSLY <br />E <br />MS 019 le'WM-cl TO <br />I TO <br />C TO — <br />A TO <br />LLIS ANY EXTRA TANKS ON A SEPERATE SHEET <br />P 110 ml�w�L (SEE ATTACHMENT WITH CONDITIONS)AIEWERS NAME ,Tj/d1C= /—�9d/L.A DATE <br />N - <br />APPLICANT MUST PERFORM ALL FORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LIFS, AND RULES AND REGULATIONS <br />OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br />IN THE PERFORMANCE OF THE WORK FOR ERICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH HARARE AS TO BECOME <br />SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT <br />TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. COMPLETE DRAWING 01 ATTICBSD PLOT PLAN SHEET. <br />CALL F ALL NEC SARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br />SIGNED X TI TLE lir�•—_ DATE: <br />ACCEPTED 41 TITLE: -DATE: <br />