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A UNDER ROUNp TANKC ..... .wnwVm `U"L MAL[" W15IRICI q <br /> IEUI E HAZELiON AVE. STD' '9N CA <br /> M CLOSUF. ABANDONMENT cele bone LB'il WGO-a.N <br /> AApAAApdAACAA.AAkAAA.^.CA.".Cd7C AAAAAdp MAC!!AAACddpdA7ddAAAApNAA:7CAANAq <br /> APPLICATION FOP. PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUiID HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE IELDUI <br /> REMOVAL ----- TEMPORARY CLOSURE -__- ABANDONMENT IN PLATE <br /> PP PROJECT CONTACT L TELEPHONE 1 <br /> CAC 000 187893AME ick Kosta 209 941-2576 <br /> BJJ PHONE 1 (209) 941-2576 <br /> 2431 E. Mari sa RodStA 95204 <br /> ETr99 Fronta e1�0�gl3JJ Cmtg' , Inc. PHONE I (209) 941-2576 <br /> C CONTRACTOR NAME <br /> 0 Precision Industries, Inc. PHONE 1 (209) 462-9911 <br /> N CONTRACTOR ADDRESS 1041 S. Pershing Avenue CA LIC <br /> T � 467293 CLASS A & B <br /> R INSURER Ohio Casualty <br /> Y WORK.COMP.1 WCW 89 400-96-87 <br /> C FIRE DISTRICT Montezuma <br /> T PERMIT I/INSPiR - <br /> 0 LAIDRATORY UK Roy F. Weston PHONE 1(209) 957-3405 <br /> R <br /> SAMPLING FIRM* Roy F. Weston SAMPLING METHOD ]crass tube <br /> TANK ID 1 TAiK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUS <br /> i <br /> A 99 ---------------------- <br /> M 37- - - >erastJ`oil _ <br /> K ]9 <br /> ]9- <br /> ----------------------------- <br /> --------------------------- <br /> I9 -------------------------- <br /> -------------------- — <br /> LIS r ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P APZ4:OVCD APPROVED WITH CONDITIONS ___ DISAPPROVED <br /> L --- <br /> �����// (SEE T ACHMEN WITH CONpITIONS) <br /> A PLAN REVIEWERS NAME L: r� - <br /> N - -- - ------------------------DATE• <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT <br /> IN THE PERFORMANCE Or THE WORT; FOR WHICH THIS PERMIT 15 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONIKACTOP.'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 01 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SURJEC <br /> iO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNET <br /> Offi ------------------------------------------------------------------------------------DATE <br /> {11111{{{f{{ltltffifffftfl l{ft{ftf{tl{ttl{{lftftfft{{ftft{fti ttl{{f{1ttt11f{fIt1$1111{11$11$mm$1{{1111mmflfffflf{fffffff <br /> SWEEPS"I ' COMP 1 'LOC CODE 'DIST CODEAMOUNT DUE AMOUNT P.CVO ' CY,1/CASH RCYO BY j DATE RCYD I PERMIT 1 <br />