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RD <br />ALTH <br />CT <br />IIAPPLICATION FOR PERMIT SAN CLOSUREUNDEROROUND TANK ABANDONMENT I 1601 TelephoneO(209)UIN LOCAL E468-34200ONICA <br />1PPLIC11101 FOR PIRMINEYT/TIMPORIIT CLOSURE OR 1811DO1NIIT 11 PLICE OF UNDERGROUND M1111DOUS SUBSTINCES STORIGE FICILITY <br />THIS PERMIT EXPIRES 10 DIPS FROM THE IPPROTIL D17I. DO NOT WRITS 11 111 SEIDID IRE1S. IIDICITE PERMIT TYPE BELOW: <br />x REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br />F <br />PROJECT CONTACT <br />J. SOUZA <br />PHONE M 209 / 838-7095 <br />A <br />C <br />FACILITY NAME <br />J.M.S.LEASES <br />ADDRESS <br />1602 E_— SECOND STREET, _—ESC. _ <br />I <br />L <br />CROSS STREET <br />PHONE 9-2ai/ 526-9871 <br />T <br />OWNER <br />PHONE M 209/ 838-2095 <br />Y <br />J. SOUZA <br />PHONE M / <br />C <br />CONTRACTOR NAME OWNER <br />N <br />CONTRACTOR ADDRESS SAME <br />CA LIC N - <br />-- -- <br />T <br />R <br />LIC CLASS _ <br />WORK. COMP. M _ <br />INSURER _ <br />- -- <br />A-- <br />— --- -- --- ---- <br />=--- —_._:—____: <br />C <br />FIRE DISTRICT _ <br />PERMIT M _ <br />- --- <br />T <br />0 <br />LABORATORY NAME CALIFORNIA WATER LAB <br />PHONE M -nc/ rr?�_nn�_ <br />R <br />SAMPLERS NAME _ <br />SAMPLING METHOD - <br />C <br />fig <br />VOLUME <br />CHEMICALS STORED <br />DATES STORED <br />CHEMICALS STORED <br />H <br />ID M <br />CURRENTLY <br />PREVIOUSLY <br />M <br />nacnlina I,. TO <br />I <br />TO— <br />c <br />TO <br />A <br />TO <br />L <br />LIS ANY EXTRA TANKS ON A SEPEIRiTE SH ET <br />��I <br />I .i q pr' II II "M0;IM01ryOn <br />APP i O ON <br />L <br />(SEE AVTACH14EUX WITH CONDITIONS) <br />A <br />PLAN REVIEWERS NAME-� a - DATE <br />N <br />All111101mm!u! <br />IPPLIC1Nf MUST PERFORM ILL TORI IN 1CCORDINCS WITH $11 JOIQUIM COUNTY OSDIWIWCES, STITE L11S, 110 RULES IND 11GULITIO113 <br />OF THE S11 JOIllum LOCIL IIILTN DISTRICT. OWNER OR LICINSED IG11T'S SIGNITURE C11TIFIES TER FOLLOWING: 11 CERTIFY TRIT <br />IS THE PERFORNIICE OF fig WORM FOR "ICU full PERNIf IS ISSUED, I SEAL NOT EMPLOY I1Y PERSON IM SUCH MIMNER 1S TO BECOME <br />SUBJECT f0 WORIMIN'S COMPSNS1T101 L1WS OF CILIFOS111.1 CONTRICTOR'S RISING OR !IU-CONTRICTINC SIGNITURE CERTIFIES THE <br />FOLLOWING: '1 CERTIFI TNIT If FHB PER/ORMINCI OF THE four FOR WHICH 1911 PERMIT IS ISSUED, I SHILL EMPLOY PERSONS SUBJECT <br />TO W011M1N'S COMPSISITION LIWS OF CILIFORNII. COMPLETE DSIWING ON 1fYICHED PLOT PLIM JE111. <br />CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br />SIGNED X TITLE: DATE: <br />ACCEPTED BY TITLE:._ �2.Ccois� DATE: <br />1� AMUUNT UUL I llEMl'1"1'!;U I CKM/CASH I RECEIVED BY - -j DATC �_PrTZRr_T I(— - <br />I <br />