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iNtiACPPLILITION FOR PERMIT rifliJOIQUliYC03: <br /> LOCAL <br /> ALM DItSiTeRi�ItCiTtik: 1A,". <br /> C: UNDERGROUND TANK �: 1601 E HAXELTOI All., STOCKTOI CAI: <br /> I: CLOSURE OR 11IDDONMENT �: TelePlooe (2091 168-7125 C: <br /> IPPLICITION FOR PIRMIMINT/1EMPORI21 CLOSURI OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTINCES STORIGE FICILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE IPPROVIL DIT8, DO NOT WRITE IN 111 SIIADtO AREAS. INOICITE PERMIT TYPE IELOW: <br /> < REMOVAL --_ TEMPORARY CLOSURE _ ABANDONMENT IN PLACE <br /> RPI S[TR 1v ;,; ----. .o ---------- --------- <br /> / ,d ,.ti PROJECT CONTICT A TELIPRONI 1 <br /> P FACILITY I1MI5�O Sv. PHONE 1 <br /> A <br /> 1 ADDREIS `-v N �G C r ce.,,1e.•-� S f <br /> L CROSS STIRET <br /> 1 � OCrch S-1- • <br /> T OYYq/OPENITOR PROVE I <br /> 5 fier <br /> C CONTRACTOR NAME <br /> 0 n e — PtlOYB I <br /> — <br /> T C0ITIICfOR IDDRISS -7 J1 -7 w'1/Ou J f CI LIC I CLANK(3/ <br /> ocr <br /> R <br /> INSURER VORK.COHP.) Y <br /> T FIRE DISTRICT PERMIT I/INSPTR I o I J <br /> ' K <br /> D LABORATORY NIdE: ! Sr.3 — /.3 10 <br /> R <br /> SAMPLING F1RM1 SAMPLING METHOD �; , ,� e r <br /> till ID 1 TIYK SIRE CHI ICILS STORED CURRIVI'Ll CHEMICALS STONED PRITIOUIL <br /> T <br /> 3 2 c C::) C2 1* <br /> 1 79- <br /> K 79 <br /> -- LIST ADDITIONAL TINK INFORMATION IS NEEDED ON SEPARATE FOIN <br /> wNNUNR1IIIUWUNMUNNYNNUNUMmualrHmunuuMNwwuuNNruuulNurAMuuurmM NNurNN <br /> P APPROVED APPROVED Vita CONDITIONS DISAPPROVED <br /> L -ME 17TACOMENT WITH CONDITIONS)-- <br /> / PLAY RIVIEWERS MIME <br /> IPPLICANT MUST PERFORM ILL MORE 11 ICCORDINCE vita SAN JOIUUIN COUNTY OR011110ES, STATE LIES, IND RULES IND REGULITIOHS <br /> OF THE SIN JOAOUIY LOCAL 181011 DISTRICT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY THIT <br /> IN THE PERFORMANCE OF THE VOIX FOR WHICH THIS PERMIT 13 ISSUED, I SHALL NOT EMPLOY ANY PERSON IM SUCH MANNER AS 10 BECOM <br /> SUBJECT TO IORKEI'S COMP8131TION LIWS OF CALIFORNIA., CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNITURB CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY THAT 11 THE PERFORM/NCE OF THE WORT FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO IORKII'S COMPENSATION Ll IS OF CALIFORNIA. <br /> TIONS AT <br /> CALL FOR <br /> L £041c/ AST-9U YIOURS INOITE ADVANCE <br /> SIGNED <br /> y <br /> OFFICE I ONLY--EH 23 <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSs'SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS I COMP ILO C CODE CODE, /MOUNT DUE AMOUNT RCVD I CKI/CISd RCYO BY O1TR KCVO PERMIT <br />