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UNDERGROUND TAN 1601 E HAZELTON 4K. , STOCKTON CA I` <br /> li CLOSURE OR ABANDONMENT If _Telephone ( 209 ) 468-3428 - fl <br /> APPLICATION FOR PERNANEIT/TEMPORARI CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND RASARDOUS SUBSTANCES STORAGE FACILITY <br /> 'IRIS PERMIT SIPIRSS 90 DAYS FROM IRS APPROVAL DATE. DO NOT YRIIE IA 11I SR111D AREAS. IRDICATE PERMIT TIPS BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACT PHONE <br /> A <br /> C FACILITY NAME ADDRESS - �� <br /> ADDRESS <br /> I ec' <br /> OWNER _r`rlrUrt� <br /> T CROSS STREET PHONE # �� <br /> i Y <br /> C CONTRACTOR NAME <br /> N CONTRACTOR ADDRES Sp() SSC CA LIC <br /> T ....- - — f--- <br /> R LIC CLASS _ WORK COMP_ 00 �C� INSURER.T Gam !/1 <br /> A --- <br /> C FIRE DISTRICT PERMIT # <br /> O LABORATORY NAME -S <br /> R PHONE # / <br /> -- �L <br /> SAMPLERS NAME SAMPLING METHOD <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID # ._.-_._ CURRENTLY PREVIOUSLY <br /> I E <br /> M / / CJS— TO <br /> I cJ —TO— <br /> C `' o —TO— <br /> A TO <br /> L ISt ANY EXTRA TANKS ON A SEPERATE SH ET <br /> P <br /> L (SEE AT CHMgNT WIT4 CON IONS) <br /> A PLAN REVIEWERS NAME DATE ^L_ r L <br /> LN <br /> APPLICANT MUST PERFORM ILL YORK IN ICCORDANCE PITR SAN JOAQUIN COUNTY ORDIWANCBS, S1AT8 GAYS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAOUIN LOCAL HEALTR DISTRICT. OYNER OR LICENSED AGE1T'S SIGIITURE C1ITIFI1S TBR FOLLOIING: 'I CERTIFY THAT <br /> IN THE PBRFORMANCE'OF THE YORK FOR YRICN TRIS PERMIT IS ISSUED, I SRALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> SUBJECT TO WORKMAN'S COMPENSATION LAYS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE YORK FOR YRICN THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br /> TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. COMPLETE DRAWING Of ATTACWED PLOT PLAN SHEET. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED X TITLE : DATE' <br /> ACCEPTED BY TITLE : DATE: <br /> In <br /> OIfIIlllhtl IfM flRltl FiAIAAMI <br />