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UNDERGROUND TAN* 1601 E HAZELTON 0, STOCKTON <br /> CA <br /> OSUI� <br /> CLRE OR ABANDONMENT Telephone ( 209 ) 468-3428 f <br /> APPLICATION FOR PERMANEIT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND RAAARUOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT SPIRES H DAYS FROM THE APPROVAL DATE. DO NOT IRITE IN III SHADID AREAS. INDICATE PERMIT 'TYPE BELOW: <br /> G-- REMOVAL TEMPORARY CLOSURE' ABANDONMENT IN PLACE <br /> F PROJECT CONTACTPHONE # -_ O <br /> ���� <br /> A - y��'u _ -_. _ <br /> C FACILITY NAME � I ADDRESS � r <br /> L OWNER ADDRESS <br /> T CROSS STREE PHONE # <br /> Y _. <br /> C CONTRACTOR NAME r r y� 4�� PHONE # ag -G'37 <br /> .CONTRACTOR ADDRESSgel <br /> � C CA LIC # � <br /> R LIC CLASS WORK . COMP . # �� INSURER ,�� <br /> A -.: - _ -- - - _- -_ <br /> CFIRE DISTRIC PERMIT # <br /> T om'.C rt��`i� � 'lf, ---- <br /> 0 LABORATORY NAME PHONE # / <br /> R <br /> SAMPLERS NAME SAMPLING METHOD <br /> C .... VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID # CURRENTLY - PREVIOUSLY <br /> M id leaclo TO <br /> C)c „� 0 TO <br /> C -TO- <br /> A <br /> /1�Jc-' � <br /> A TO <br /> LMIME <br /> LIS ANY EXTRA TANKS ON A SEPERATE SHEET <br /> NAURU <br /> _P_ -- <br /> L (SEE ATTACHMENT WITH CO I)I TI ONS) <br /> I A PLAN REVIEWERS NAME " DATE <br /> u a Ilir <br /> APPLICANT NUST PERFORM ALL YORK IN ICCOROAHCE WITH SAN JOAQUIN COUNTY ORDINANCES, STAT$ LAYS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAOUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGIITURE CERTIFIES TNR FOLLOWING: 'I CERTIFY THAT <br /> IN TRE PERFORMANCE'OF THE WORK FOR WHICH IRIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MINNER IS TO BECOME <br /> SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY THAT IN THE PERFORMANCE OF THE YORK FOR FHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br /> TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. COMPLETE DRAWING OI ,ATTACRED PLOT PLAN SHEET. <br /> CALL FOR ALL NECESSARY INSPIaCTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED X TITLE : _ DATE: <br /> ACCEPTED BY TITLE: DATE: <br /> mua���u�i�I1I`�o�nHi�nn�amm�uwiwanai�eeaii�an�ina�ai��il"iamaaaniaaaina�n�an�'wxai�aaniananmA�a�afram�n�+wu�ninamiasnian��mm�u�ar�aii!uaana�naaemaaana�r�asuamAara�.n€a�mieaal�!nlmnpa �nna�aaaa�asann�iaa�annnatia�nra <br />