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APPLICATION FOR P iTSAN JOAQUIN LO IEALTH DISTRICT <br /> ' UNDERGROUND TANK II 1601 E HAZELTON AVE. , STOCKTON LA <br /> I]- CLOSURE OR ABANDONMENT Telephone ( 209 ) 468-3428 <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PEHJIIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ISY SHADED ARRAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> _..._: _:_::. <br /> - ::.._ PHONE # aL( / 6121 - II IDU <br /> F PROJECT CONTACT Zp"cnJ MAR(y0w�j (I <br /> A ------- - --- - --- - . ._ 1 ... �i <br /> C FACILITY NAME R pL ADDRESS '0+gjy p(IFIG. L\+JI✓ <br /> - ... ­---- ............. ------- _.. <br /> I OWNERCaCk(� ADDRESS <br /> T CROSS STREET Y�UvS PHONE # / <br /> Y <br /> C CONTRACTOR NAME <br /> 0 'r OWtJ �� r PHONE # g�/ IL IS�aII <br /> N ......... .... _ __._ .__.._..._... <br /> N CONTRACTOR ADDRESS 11? O GING �1$ CA LIC # (R/D)r' <br /> T I -- TT - - --- <br /> R I LIC CLASS WORK COMP # INSURER <br /> A `_ __- . . <br /> C FIRE DISTRICT g4L4 SZ-1 <br /> I 1 PERMIT # <br /> 0 LABORATORY NAME Aftl c D 1 5Y5 PHONE # quo <br /> R ----- - - -- — ---------- ------_._... - -------. <br /> SAMPLERS' NAME K4i -�QmS(/�}D I SAMPLING METHOD - <br /> �� NVINN pN�lll l INNIIININ� —� <br /> CHr ___ .. . <br /> C � VOLUME EMICALS STORED DATES STORED I CHEMICALS STORED I <br /> H ID # CURRENTLY PREVIOUSLY <br /> E _ — — ----— — — _ — _ _.. ._. <br /> ..__...._ ._......._.....I <br /> M U l',L TOGu <br /> I c 0 0 0fl 2C—moi. T <br /> C ill p TOGIA <br /> A � I� <br /> I TO <br /> �� Gp��� LIS ANY EXTRA TANKS ON A SEPERATE SH ET <br /> ==P-=j. IINIiNull !�IlNlill� ui�l !N'll' I NNINIIIINNIIIINIIN!INININI NII !'I' I I III , IIIIIN.I ' !'I MINI N' 11 !!I '!!I!°! II iN!IP! !'i u'i i� I II,; I, •. !illll !�! I,I„ ,�;I!I <br /> L Il � SII IVIIIII,IIII�II �11�CIIN1I� fIN�N�NIINiIVINIINIIIIIII�IINIIIIAiNNINiIIIiIIIIhIVIIiIINII!!NiNiIIII <br /> (S E ATTACHM N WITH CONDITIONS) <br /> A A <br /> A PLAN REVIEWERS NAME DATE 3 <br /> N pu <br /> ---- 61. !I6!1!1!11IT11NII�IIN�Ni!II!NNIIN!ININX1IV0INu�IININN!NIII!�i lI��IVl!�6uINIINI�NNrIINI6!NNIII!IIV!NI�I!Il'16u�lN!IINIl�!!!�l!l!�0l��1�'IINu�!�uIN�INu�I!NIuJIIN!d!�I!J!I�IlI�n�l iNIN !pY V;IIII�III UuINNINmI11111 <br /> 1 �RILv111 VNIN �uiI�!VIIIN! 111!91PI!!nl 11111 <br /> l!INI�� �N:�N �� <br /> ll1! 4I'II�ti Ni VIll��rillm�u1l!��uIll:!;�y!Ii�IfII�i„!^uI�u!��^i <br /> APPLICANT MUST PERFORM ALL YORK IN ACCORDANCE FITR SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OYNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TNR FOLLOWING: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> SUBJECT TO WORKMAN'S COMPENSATION LAWS 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 LAYS OF CALIFORNIA. COMPLETE DRAWING ON ATTACSED PLOT PLAN SHEET. <br /> CALL OR ALL N • 'ESS Y INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED X TITLE: DATE: ' 0,2) <br /> ACCEPT D BY 1dI TITLE: p II/JG/�`i1//liw� DATE: /0 /3 � <br /> pp� III „!u �IINN��IuIiN !�oIlli 'NVNiNII. N'I'" I, �o "� Iw 'INNV MINNjpJ iIaiINNNI�IIIIN'.INN'"'NNiNii � 'I" Nl i�N!NIiNNNii l !N! <br /> IIV�wWV�IVZ�dViCllll tl�IImIIIIIVIIHIWSIIVIVtiAllll�NltlIiV91WVVII�VVH�N11191N�IVIIUUIIIIIII�IIIVIIEII�IIdN�IIMM�IIUNiIIBVGIIhMVIIIiIIVNItlNUI81�V51�9GIIN IVVtllll' Vitl'' SWNI9IMIIVVVNBI�u WIiHV NWINI&NVNIII�I�IIVVtlI�It18iVII811tlIIIVVIIViVIVINI�V#fI�IIIVVII� <br /> 8111WIIIIIIIIIIIWIWtlIW111161UWIIW➢WIllWIIIIIuiIgIry�NIIIWIyIµC�;ulnl"IiN�IUJNWiII�I�IWW.tlWWNInIIIIRmA!Agtl�BWIA,}miI�IOIInIIIn:n'.Irlu"nIIp11lOWPltuglnrl ltY1916NV""I@NYWIu p,nnlin A4.Vpq"UVmii"u'rI.urunlUuPVd9i14V o-i nul. nn:�.n!.mi!r�pill r.n.I 14n n�.uglq�nll <br />