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APPLICATION FOR PER SAN JOAQUIN LOCALVALTH DISTRICT <br /> UNDERGROUND TANK 1601 E HAZELTON AVE. , STOCKTON CA <br /> CLOSUREIL- OR ABANDONMENT Telephone ( 209 ) 468-3420 <br /> IPPL1CITIOU FOR PIRMIJ11TITEI{PORIRY CLOSURE OB 16I10OMNSNT 1N PL1C8 OF UNDERGROUND lzlilQDOUS 5UBSTINCES fOR1C6 FACILITY <br /> I ITY <br /> `UIS PSPMI IHISS SO DITS IRON fit 1PPSDTIL 11171. DO NOT FRITS 11 all SSIDSD IRE17. IIDICITB PERMIT TIPR BELOW; <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACTD PHONE D <br /> A C� <br /> C FACILITY NAME ADDRESS <br /> L CROSS STREET/ <br /> G G;ti' L/. /(J PHONE / `" 73 <br /> 575 <br /> T OW14ER �t ,� f //�� PHONE <br /> 10 <br /> C CONTRACTOR NAME )/} y�� PHONE # q to 2-15" <br /> N CON'T'RACTOR ADDRESS f1 CA LIC <br /> T <br /> R LIC CLASS <br /> A WORK . COMP . i1 �l31 '�' rC� INSURERS <br /> — _ <br /> C FIRE DISTRICT � Q -� PERMIT,40- 1 ? ? <br /> 0 LABORATORY NAM'E.� v PHONE # <br /> R <br /> SAMPLERS NAME SAMPLING METHOD <br /> C j; K VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID # CURRENTLY PREVIOUSLY <br /> E4--- -- <br /> l�f TO F . <br /> TO- <br /> c I TO <br /> TO <br /> L LISt ANY EXTRA TANKS ON A SEPERATE SH ET <br /> PA 'PROVE <br /> L7J <br /> (SEE AT gU,KENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME DATE <br /> N <br /> IPPLICIIT NUST PERY09H ILL FORK IN 1CCORDINCE FITN $II JOIQUIN COUNTY OROININCES, STITE LIPS, 111) ROLES IND RECULITIOIS <br /> OY THE STY JOIQUIY LOC1L 11101 DISTRICT. OFIER OR LICENSED 1811T'S SICIITUR6 CRftIFIES TNR FOLL01II6: 'i CERTIFY CHIT <br /> IY THE PERFORNAICE OF TBE FO1C FOR FY1C9 TRIS PIRNIT IS ISSUED, I SI1LL #01 %!(PLOT lit PERSON is SUCH NINI£R IS TO BECOME <br /> SUBJECT TO FDRINIY'! CONP11SITIO1 L1FS OF CILIFORIII." COI1110OR'S 111ING DR SU1-CIMTRiCTINC SIGYITURE CERTIFIES TBS <br /> FOLLON11C: 'I CE1TIF1 TY1T IN THE PIRFORNIICB OF THE 1091 FOR WWI TRIS PERNIT IS ISSUED, I S11LL EMPLOY PSRSOIS SUBJECT <br /> TO FORININ'S CONP11SITION LIPS OF CILIFORYII, CONPLET$ DRIFING 011 1TTICIRM PLOt PLIY !BEST. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED X TITLE: DATE.• <br /> ACCEPTED BY TITLE: DATE: <br />