Laserfiche WebLink
1\ 4 1 <br /> �j UNDERGROUND TAa 1601 E HAZELTON r,vE. , STOCKTON;CA +� <br /> ` CLOSURE OR ABANDONMENT II Telephone ( 209 ) 468-3428 <br /> APPLICATION FOR PERMANISIWimp ORIRI CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND EAHRDOUS SUBSTIICES STORAGE FACILITY <br /> THIS PERMIT 11PIRES 90 DAYS FROM TIE APPROVAL DATE. DO NOT YRITE II 111 SHIPID AREAS. IIDICITE PERMIT 71PE BELOW: <br /> T REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> ��- F PROJECT CONTACT/W/ --_-- M 1�-" PHONE # � �/ <br /> C FACILITY NAME /,/�9,0TEW 9gX _ ADDRESS <br /> I �J. <br /> f L ^WNER ADDRESS <br /> T CROSS STREET PHONE # <br /> Y <br /> CONTRACTOR NAME --7 - PHONE <br /> �I N , CONTRACTOR ADDRESS &) CA LIC # <br /> R L 1L,�;Lo�,o <br /> LIC CLASS WORK . COMP . # INSURER '1-1f11bte <br /> C FIRE DISTRICT PERMIT # <br /> rT — --- —_ .- <br /> O LABORATORY NAME v PHONE # <br /> R <br /> SAMPLERS NAME SAMPLING METHOD <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID # CURRENTLY PREVIOUSLY <br /> i E <br /> M a /U TO&� <br /> I TO -- <br /> C TO`� <br /> A TO <br /> L LIST ANY EXT -A TANKS ON A SEPJII;RATE SH ET <br /> P <br /> L (SEE ATTA ENT WITH CONDITI ►VS) <br /> PLAN REVIEWERS NAME caL2 u � DATE <br /> LA E <br /> APPLICANT MUST PERFORM ILL LORI IU 1CCORDII►CE FITS $11 JOAQUIN COMITY ORD11110ES, STITE LITS, 111) RULES AND REGULIV OIS <br /> OF 79E SAN JOIQUIN LOCAL BFILTH DISTRICT. 011ER OR LICENSED AGENT'S SIGIITURE CIIIIFIIS TH1 FOLLOWING: 01 CERTIFY ?BIT <br /> IN THE PERFORMANCE OF fig FORK FOR 1RICH THIS PERMIT iS ISSUED, I SHALL NOT EMPLOY 11Y PERSON 11 SUCH N1N1EI 1S TO BECOME <br /> SUBJECT TO WORKMAN'S COMPHISITIOI L11S OF CILIF01111." C0ITRACTOR'S HIRING OR SUB-CON711Cf11G SIGIITURI CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHILL EMPLOY PIRSOIS SUBJECT <br /> TO YORIMIN'S COMPENSATION NIS OF CILIFORIII. COMPLETE DRIIING O1 ITT1C11D PLOT PLII SHIFT. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> r' <br /> SIGNED X „� c t c TITLE: ✓�J DATE: r <br /> ACCEPTED B -_�, ', _T /� <br /> TITLE: �s�_ ti _ � �.� DATE: cS , <br /> ... .=; - <br />