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APPLICATION FOR PE W T SAN JOAQUIN LOCA H�ALTH DISTRICT <br /> UNDERGROUND TANK 1G01 E HAZELTON AVE. , STOCKTON CA <br /> CLOSURE OR ABANDONMENT Telephone ( 209 ) 468 -3420 <br /> IPPLICITIOX FOR PIRKIIINT/TIMPORIRT CLOSURE OR IIIIDOWNRIT 11 PLICR OF UJDERGROUID RIiIRDOUS SURSTIJCES STORAGE FACILITT <br /> THIS PRRMIT RIPIRRS 10 DITS IROK TRt IPPROFIL D1Tt. DO JOT VRITI II III SEIDID IREIi. IIDICITR PYRKIT TIPS BELOY: <br /> _ REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACT R0tj LPHONE R "-�o 9 <br /> A . <br /> C FACILITY NAME IQ � �� ADDRESS J '3;;�© UO , Wt [�' � S1 <br /> I <br /> L GROSS STREET PHONE <br /> z <br /> OWNER �a5 ��,yv��s faC �ST PHONE �fl3 / 1��4 - g 55 �' <br /> tj T- <br /> C CONTRACTOR NAME, PHONE <br /> 0 <br /> N CONTRACTOR ADDRESS,L}. j WEST kow & m0a's-1--o CA LIC It C qI �G4 <br /> T <br /> R LIC CLAS S r �,-(o WORK . COMP . R O� �"�� INSURER <br /> A __CLASS <br /> — — — <br /> C FIRE DISTRICT ' 0� -`-� � � �$ PERMIT # <br /> T <br /> 0 LABORATORY NAME NA 16K PHONE k po <br /> R <br /> SAMPLERS NAME CO,(_. WATLC �_A6 SAMPLING METHOD <br /> s, tyJ ` •a� LY) 0 <br /> C TANK VOLUME CHEI4ICALS STORED DATES STORED CHEMICALS STORED <br /> H ID # CURRENTLY PREVIOUSLY <br /> E <br /> M TO 1;2-%?> rJ�q <br /> I 1 l 1 f:L TO la-Fir <br /> it <br /> C _ 000 UrIL _.��3sQin!II TO. ip- to NIA <br /> TO <br /> ' L LIST ANY EXTRA TANKS ON A SEPIERATE SH E ET <br /> P MOM <br /> L (SEE ATTACHMEN WITHCONDITIONS) <br /> LN <br /> PLAN REVIEWERS NAME Com,/ DATE <br /> IPPLICII'T MUST PERFORM ILL PORI IX ICCORDIMCI PITH SIX J01OUI1 COUITT ORDIJIYCES, ST1TE LAYS, IID RULES AMD R$CULITIOIS <br /> OF THE SIX JOIOUJI LOCAL tt1LTH DISTRICT. DIRER DR LICEISED 19117'3 SICIITURE CEitIFIES THR FOLLOIIXG: 11 CERTIFT THAT <br /> IX Tot PIRFORIIIXCE OF THE PORI; FOR YHICI THIS PERMIT IS ISSUED, I Sim XOT EMPLDC ar PERSDX IX SUCH MIMIER AS TO BECOME <br /> SUBJECT TO YORKMIX'S COMPIISATIOI LI YS OF CILIFORXII.' COXTRICTOR'S 111110 OR IVI•CNTRICTIIG SIGIITURE CERTIFIES TEE <br /> FOLLOYIIG: 'I CIRNP'I NIT IX THE PERFORMIXCE OF THE YORK FOR FRICI TYIS PERKIT IS ISSUED, I SHALL EMPLOY PIRSOIS SUBJECT <br /> TO IORIXII'S COXPIISITIOI L1YS OF CALIFOR111, COXPLITZ DRIYIIC 09 ItTICRED PLOT PLIX SHEIT. <br /> CALL/-T ALL NECESSAR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED X v TITLE: DATE% ek <br /> ACCEPTED BY !TLE: DATE: <br /> � LD � 7 <br />