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�i UNUEKGkUUNU TANK• IbUl E HAZELTUN AVE. , STOCKToN CA <br /> t` <br /> CLOSURE OR ABANDONMENT li Telephone ( 209 ) 46H- 342H II <br /> APPLICATION FOR P ANENT/TEMPORART CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT SS 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> - - - — <br /> F I PROJECT CONTACT I PHONE N <br /> A �{2 rG M p......�sAn�o <br /> IFACILITY NAME pG E — ADDRESS ,214 Tl2ACY..-,_� <br /> L OWNER ADDRESS p CJ aO a�0 �} }IOC�I. <br /> �C E �`�Is�_ 9 ygo) . . X ✓1 <br /> I _ t / _....... <br /> T j CROSS STREET �' 1 Q PHONE N om/ e3s- IG'IS� <br /> i Y i . .. -. . . ... v.KSf_ oVV'C. �OS .. <br /> C CONTRACTOR NAME CPHONE N flS / S6� SSI <br /> O 1 - ---- — - - .�t1QA ? ._�QYIS( 0 I --- <br /> T I CONTRACTOR ADDRESS 9220 / ©A{'rIAoU� i CA LIC <br /> ------------ .. ._... .. ._ -r- <br /> RA LIC CLASS I WORK COMP N WCO3C7 �fq& INSURER <br /> C- — =I__ .... _. <br /> _..—� <br /> C FIRE DISTRICT I PERMIT N <br /> T 11 <br /> !'Ll <br /> 0 LABORATORY NAME ��1 PHONE M <br /> R ---- - ---- - _�RKIE <br /> SAMPLERS NAME I SAMPLING METHOD <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> i H ID N CURRENTLY PREVIOUSLY <br /> E <br /> M o2 /COU UO%4cleW TOf2a i <br /> I TO <br /> C TO <br /> A I TO _ <br /> LLIS ANY EXTRA TANKS OCET <br /> N A SEPERATE SH <br /> L (SEE ATTAC NT .WITH GONDIT- ONS) <br /> ' A PLAN REVIEWERS NAME DATE <br /> N <br /> _-` I� ��J1 �9 1lINNNI N �ftlIII� N0111111111NN 'N4111i 1 °I ''f�Np9i�P�9 4 Gn �4N ImfptiV G�l91 SN iliAilIflmh 'II1 d:;ffi ?Ii Nu INS willillGN mi 4�4 iNlh�fiNviuNri �l <br /> APPLICANT MUST PERFORM ALL FORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAYS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGWATURE CERTIFIES THR FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> SUBJECT TO WORKMAN'S COMPENSATION LAYS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: '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 BRAYING ON ATTACHED PLOT PLAN SHEET. , <br /> CALL FO A NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED X --_ TITLE: `fj DATE: <br /> ACCEPTED BY TITLE : DATE: __,_ <br /> G�WII�I'�FH' II�NN'INBINtlINRtlNNNH6AICIiIIDNNBNNNtlIN�E01WItlNtlItlDINI1tlBHDN�°IINNDIYtl�INiVWvlllN�NY"6111NVN@NDWINABVBUDIBIIBUNIiIMNN�NtlIYDBWNNIAI�tiIIWww!WIDdVBNINiNtlIEgNWtl;�I!IBm1191WNiNSWONNNBNIIWNtlDNNV9IN�CUMINNNVODNIiL11Gl <br /> AMpIIIIIUIgiPNINIIIINiIMIPNIIIUTANIYIIiINIli011tlWANMIII1111gtlMiIIIXIgXtlIIXIIIItl11XIlAIaAIpINtlMWMIIIXXGWpIXGI%IINNNXIIANIpINLUNIIIINIIIIIIItlIIIAlII1111111WI1011tlnnnlAilllgPxlINIVIIINF'IAIiA'IIII;PT'YdiPIH14GII�ItlCiiil!idl'.v4nlitlllplWllf4lAllMNlll'!IIAigIIMII'tlN01fIIIl01iNgXIiInIIpAbIIIIpIItlNAN <br />