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T, <br />APPLICATION FOR PERMIF <br />UNDERGROUND TANK <br />CLOSURE OR ABANDONMENT <br />SAN JOAQUIN LOCAL 7ZALTHfDISTRICT <br />1601 E HAZELTON AVE., STOCKTON CA <br />Telephone (209) 468-3420 <br />IPPLICITION FOR PIRMIIBIT/TEMPORIIT CLOSURE OR 1811DOIN11T II PLACE Of UNDERGROUND 1111RDOUS SUBSTIICIS STORAGE FICIUTT <br />THIS PIRMIT EXPIRES BD BIIS IIOM THE 1PPROTIL D1T1. DO NOT HITE II 111 SHIDED IRE/S. IIDICITI PERMIT TTPE BELOI: <br />XX REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br />F <br />PROJECT CONTACT Aldo Freggiaro <br />PHONE # 209 / 946-0246 <br />A <br />C <br />FACILITY NAME Port of Stockton <br />ADDRESS 2201 W. Washington, Stockton, CA <br />I <br />L <br />CROSS STREET <br />PHONE # 209/_946-0246 <br />I <br />T <br />Y <br />OWNER nA PHONE # je / gSVGY03y6 <br />Po R,% oT <br />C <br />CONTRACTOR NAME JIM THORPE OIL, INC. PHONE # 2 O 9 / 462-4581 <br />0 <br />_ <br />N <br />CONTRACTOR ADDRESS 351 N. Beckman Rd., Lodi <br />CA LIC # 495699 <br />T <br />R <br />LIC CLASS A <br />WORK. COMP. # on file <br />INSURER on file <br />A <br />C <br />FIRE DISTRICT / <br />5racleTON <br />PERMIT # <br />T <br />O <br />LABORATORY NAME Canonie Environmental <br />PHONE # 209 / 983-1340 <br />R <br />SAMPLERS NAME <br />SAMPLING METHOD <br />C <br />VOLUME <br />CHEMICALS STORED <br />DATES STORED <br />CHEMICALS STORED <br />H <br />ID # <br />CURRENTLY <br />PREVIOUSLY <br />E <br />M <br />12,000 #6 Crude Oil <br />TO �Rxp¢oi< <br />I <br />TO <br />C <br />TO <br />A <br />TO <br />L <br />LIS ANY EXTRA TANKS ON A SEPERATE SH ET <br />n W MIRM—Mmnii-M, <br />NONDITIONS) <br />p <br />L <br />(SEE ATT A NT NT WITH <br />A <br />PLAN REVIEWERS NAME DATE <br />N <br />'L/�e <br />mmavenm�mm�na+Mn <br />IPPLICIIT NUSf PREFORM ILL PORI IN 1CCORDIYCI YITB SIX JOIDUIY COUNTY ORDIIIYCIS, ST1TE LIPS, 110 RULES IED R9CULlTI0Y5 <br />OF THE $11 JOIOUII LOC1L IXILTR DISTRICT. DINER OR LICKI39D 1GNIT'S SICIITURY C1111FIES TER FOLLOIIIC: 'I CERTIFY THIT <br />II THE PERFORN11C1 OF THE FORT FOR IBICI THIS PERNIT IS ISSURD, I SKILL NOT IMPLOI III PERSON II SUCH NINYYI IS TO BECOME <br />SUBJECT TO FORXNII'S CONPINSITI01 ills OF CILIFORNII., COATI an's MIRING OR SDI-CONTRICTINC SICIITURY CERTIFIES THE <br />FOLL01110: 'I CIRTIFT THIT 11 THE PERFORM/NCR OP THE YORK FOR FIICH TILS PERMIT IS ISSUED, I SHILL EMPLOY PIRSOl3 SUBJECT <br />TO FORXMII'S CONPE131TI01 LIPS OF CILIFOI/11. COMPLETE DRIYINC ON 1TTICHYD PLOT PL1M SHIll. <br />CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br />SIGNED <br />ACCEPTED BY <br />TITLE: <br />TITLE: <br />DATE: <br />DATE: <br />