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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT <br />UNDERGROUND TANK 1601 E HAZELTON AVE., STOCKTON CA <br />CLOSURE OR ABANDONMENT Telephone (209) 968-3920 <br />APPLICATION FOR PIIMINIMT/TRMPORIIT CLOSURE OB IBAWDONMIYT 10 ?LICE OF UNDERGROUND HAZARDOUS SUBSTANCES STOIAGE FACILITY <br />THIS PERMIT EIPHIS TB DAYS PROM TNR APPROVAL DATE. DO MOT W117E 11 111 SBIDID AREAS. 1MDICITE PIRMIT TYPE BELOW: <br />x_ REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br />APPLICANT MUST PERFORM ILL PORI 11 ACCORDANCE VITO 511 JOIUUIB COUNTY ORDINANCES, STATE LIPS, AMD RULES AMD REGULIT10WS <br />Of THE 511 JOIUUII LOCAL REILTM DISTRICT. OWMEI OR LICENSED AGIIT'S SIGIITURH CIITIFIES TER FOLLOWING: 'I CERTIFY THAT <br />IN fog PBRFORMIECE OF log EORf FOR WHICH fill PERMIT IS ISSUED, I SMALL MOT EMPLOY ANY PERSON IN SUCH MIMME/ IS TO BECOME <br />SUBJECT TO WORKMAN'S CONPENSITION LAWS OF CALIFORNIA.' COITRICTOR'S 91RING OR 5UA-COMTRICTIMC SIGNATURE CERTIFIES THE <br />FOLLONIIG: 01 CIRTIFI THIP IM THE PERFORMANCE OF THE WORK FOR ERICK TMIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT <br />TO WORIMIM'S COMPENSATION LAWS OF CALIFORNIA. COMPLETE DRIVING OM ITT1CHED PLOT PLAN 39181. <br />CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 98 HOURS IN ADVANCE <br />SIGNED X _ TITLE::�� DATE: <br />ACCEPTED BY ��n TITLE:JDATE:. /!( <br />PHONE 838-2095 <br />—.. -- --- — <br />F <br />PROJECT CONTACT <br />J. SOUZA <br />A <br />C <br />FACILITY NAME <br />J.M.S.LEASES <br />ADDRESS <br />1602 E._SECOND _STREI;T,ESC_,., <br />I <br />— <br />L <br />CROSS STREET <br />PHONE #_721 / 526-9871 <br />T <br />OWNER <br />PHONE # 209/ 838-2095 <br />Y <br />J. SOUZA <br />C <br />CONTRACTOR NAME OWNER <br />PHONE I _/ - SAME <br />- ----- <br />0 <br />— <br />------ <br />N <br />CONTRACTOR ADDRESS SAME <br />- <br />CA LIC I - <br />-- -- <br />T <br />R <br />LIC CLASS _ <br />WORK. COMP. # _ <br />INSURER _ <br />- <br />A— <br />-- - ----- ---- ------ <br />- ----_::__-:_ <br />C <br />FIRE DISTRICT_ <br />r PERMIT # _ <br />0 <br />LABORATORY NAME CALIFORNIA WATER LAB <br />PHONE # tea/ 52�-40;U <br />R <br />SAMPLERS NAME _ <br />SAMPLING METHOD - <br />C <br />qNsm <br />VOLUME <br />CHEMICALS STORED <br />DATES STORED <br />CHEMICALS STORED <br />H <br />ID # <br />D <br />CURRENTLY <br />PREVIOUSLY <br />- --------- <br />E-- <br />— --- <br />M <br />nacnl i nal) I,. TO - - <br />I <br />TO <br />C <br />TO— <br />TO <br />L <br />LIS ANY EXTRA TANKS ON A SEPERATE SH ET <br />" il' 11,1 <br />P <br />L <br />A <br />(SEE ATTACHMENT WITH CONDITIONS) <br />PLAN REVIEWERS NAME - 1'i; DATE <br />N <br />APPLICANT MUST PERFORM ILL PORI 11 ACCORDANCE VITO 511 JOIUUIB COUNTY ORDINANCES, STATE LIPS, AMD RULES AMD REGULIT10WS <br />Of THE 511 JOIUUII LOCAL REILTM DISTRICT. OWMEI OR LICENSED AGIIT'S SIGIITURH CIITIFIES TER FOLLOWING: 'I CERTIFY THAT <br />IN fog PBRFORMIECE OF log EORf FOR WHICH fill PERMIT IS ISSUED, I SMALL MOT EMPLOY ANY PERSON IN SUCH MIMME/ IS TO BECOME <br />SUBJECT TO WORKMAN'S CONPENSITION LAWS OF CALIFORNIA.' COITRICTOR'S 91RING OR 5UA-COMTRICTIMC SIGNATURE CERTIFIES THE <br />FOLLONIIG: 01 CIRTIFI THIP IM THE PERFORMANCE OF THE WORK FOR ERICK TMIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT <br />TO WORIMIM'S COMPENSATION LAWS OF CALIFORNIA. COMPLETE DRIVING OM ITT1CHED PLOT PLAN 39181. <br />CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 98 HOURS IN ADVANCE <br />SIGNED X _ TITLE::�� DATE: <br />ACCEPTED BY ��n TITLE:JDATE:. /!( <br />