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II UNDERORuUND TANK jI IbUl E HAZEL-VON AVE . , =TOCKTON CA II <br /> CLOSURE OR ABANDONMENT II Telephone ( 209 ) 468-3428 <br /> APPLICATION FOR PERMANEIT/TEMPORIRT CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS Pl!9MYIRSS 10 DAYS FROM THE APPROVAL DITS. DO NOT WRITE IN IIY SHADED ARI1S. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> rF1 PROJECT CONTACT PHONE N aGI/ L1,31 Ie2� <br /> A ----- k(.I-Cyl�__ <br /> C FACILITY NAME IIJ n 1_ ADDRESS <br /> L OWNER ADDRESS <br /> T CROSS STREET _.3��-75 Nw `/ <br /> I PHONE N / Sf3S'&oSS' <br /> I .Y 1L ----------- - _ <br /> C CONTRACTOR NAME r PHONE N 2C ;L <br /> N CONTRACTOR ADDRESSCA LIC N <br /> T I - - Uo�_ <br /> R LIC CLASS WORK . COMP . N I INSURER <br /> C FIRE DISTRICT I PERMIT N <br /> 0 LABORATORY NAME PHONE M / <br /> SAMPLERS NAME SAMPLING METHOD <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID N CURRENTLY PREVIOUSLY <br /> E __.__ ..... ---— <br /> M I O LPa�Q2� Sc�Cc��ln TO <br /> Ll <br /> I -TO--- <br /> C TO <br /> A TO i <br /> L LIS ANY EXTRA TANKS ON A SEPERATF. SAF.T <br /> j� P <br /> L (SEE ATTA ENT WITH OND I T IONS) <br /> A PLAN REVIEWERS NAME <br /> q�I � ryrD�pATE <br /> N � iwNNYNwII' �di'dI���1�u�IN�wx"'Ri Ni W�"w IINNNI <br /> APPLICANT MUST PERFORM ILL WORN IN ACCORDANCE WITH SIN JOIQUIN COUNTY ORDININCES, STATE LAYS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCIL HEILTH DISTRICT. OWNER OR LICENSED AGENT'S SIGYITURE CERTIFIES THE FOLLOWING: 'I CERTIFY ?HIT <br /> IN THE PERFORMANCE OF TBE WORE FOR IHICH THIS PERMIT IS ISSUED, I SHILL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> SUBJECT TO WORKMAN'S COMPENSATION LIWS OF CALIFORNII." CONTRACTOR'S HIRING 08 SUB-CONTRACTING SIGNATURI CERTIFIES THE <br /> FOLLOYING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br /> TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. COMPLETE DRAWING ON ATTACHED PLOT PLAN SHEET. <br /> CALL F LL NECESSARY INSPECTIONS AT LEAST 98 HOURS IN ADVANCE <br /> SIGNED X �\=J - TITLE __----- DATE: <br /> ACCEPTED TITLE: DATE:ON <br /> _ <br /> �WAINWOUNNMiAaMYMMrNM1IliIMMAxAIeunANMupNn�nMIAntlIWMAd1�mmMm�mnnimwmM51NPo1Xlmrll:NxmmwMarc�m�wxemnax�nngmwvn�mMn!ummmlXmmA1NN11i <br />