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APPLICATION FOR PERMIT SAN JOIQUIN LOCAL HEALTH DISTlleft: <br /> k: UNDERGROUND TANK k: 1601 E HAZELTON AVB., STOCKTON CAI.: <br /> k: CLOSURE OR ABANDONMENT I.: Telephone (109) 168-3110 k <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> ?HIS PERMIT 91PIRES 90 DAYS FROM THE APPROVAL DITE. DO NOT WRITE IN III SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> x- REMOVAL TEMPORARY CLOSURE —_ ABANDONMENT IN PLACE <br /> EPA SITE dCAC 60�a 7a ^�a/ I ROJBCT CONTACT l TELEPHONE I Larry Moorman <br /> F FACILITY NAME stems Moorman 's Water S PHONE d <br /> A --- — y (20 9_) 931 -3210 <br /> __..... <br /> C ADDRESS 2120 Wilcox Rd. Stockton, CA. 95205 <br /> L CROSS STREET Waterloo Road <br /> T OWNER/OPERATOR PHONE I <br /> Y Larry Moorman same <br /> C CONTRACTOR NAME <br /> 0 Moorman's WaterSystems PHONE d— same — <br /> N CONTRACTOR ADDRESS 2120 Wilcox Rd. CI LIC 1 468816 y TM CLASS C 61 <br /> R INSURER WORK.COMP.1 <br /> =-L ! j ! Lt, <br /> _11S�u.rslt1 _e_ State Fund <br /> C FIRE DISTRICT Waterloo-Morada PBRMII 1/INSPTR <br /> 0 LABORATORY NAME F.G.L. Labs 1PHONE <br /> R ._._._—____.____ ____.._.__ _ d 942-0180 <br /> SAMPLING FIRM* F. G. L. LABS SAMPLING METHOD <br /> _ <br /> -- UIIII;!!UUUIUUIINUUWIIUIUUUIUIUIIIUIUIUIUUUIUIUUUUUUIIIWiUUiIUUUUIIUI ---•—•-----�_._.__—.._ ._�_____ ____—*-*'-'L' <br /> _ <br /> TANK ID 1 ?INK SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> T <br /> 1 39--,�77-/ -- —�1RQQ�c1] �_, ._ _ NQne _ Re as <br /> N 39- <br /> K <br /> 9-K 39- ----- <br /> 39•— --_ -- - —--—_—_ -- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORK <br /> UIIIIUUUiUIIIIIUUIUIWUIIIIIUUIIUiIIIUIIUUWUUUUUUKIIWUIIUIIIIWIIIUIIUIL�IIIIU HUUIIIIiU UWIIIIIIIIIIIIIIIIUIIIII!!HIUIIIUUIi!VIII"IIIA!IliiUIUIUIIGUIL'IIUUI!IIIIIU!!;!Illll!IU!U9UJIII!!I litlU6'al!.I Ii.CIIIUIIIIILI!U!IUI6�IIIIIU661ULIIUIIIIIIIIJIIUIIU 6UUUIUIIIL!ILIUUiI!hlllllUl!91UIUIUUIIUUIK I <br /> L _ APPROVED --APPROVED WITH CONDITIONS _ DISAPPROVED <br /> L - SEE ATTACIIM N WITH COYDITIONS) — <br /> A PLAN <br /> REVIEWERS NAME� � <br /> _-DATE <br /> NRUwUIKUBRRRUBUdRUUUKUIRRIWUO�UIUGUIUUYYIWRYfBWWUUIUIIUNUYIUUWU0UU11WWUUII�IUUIIWYKWI�iIU�uUIIWIBNUIUUIU!U!UIUUIUNUNUU�NUUIWWURUYWtUUUiUUUUIIfMWUUWUUI!quIUUI�IYYIfWUUIKIU81iUYIWIUIIUUUI000U <br /> APPLICANT MUST PERFORM ALL YORK 11 ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THB SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I 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 BECOM <br /> SUBJECT TO YORKER'S COMPENSATION LAYS OF CALIFORNIA.' CONTRACTOR'S HIRING CR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF TIIB WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUDJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA, <br /> CALL FOR INSPECTIONS AT LEAST Oil HOURS IN ADVANCE <br /> SIGNED___ _� '�_ 5 —DATE <br /> — ------_.—__._-- <br /> OFFICE USB ONL EII 23 ---- <br /> SSS$$SSSSSSS$SSSSSS$SSSSSSSSSSSSSSSSSSS$$S$SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS$SSSSS$SSSSSSSSSSSSSSSSSSSS$SSSSSS <br /> SWEEPS I I COMP I �LOC CODE IDIST GCCOODE' IM U UE AMO RCVD CKI/CASH RCYD BY DATE RCVD PERMIT 1 <br />