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4 <br /> APPLICATION FOR AN JO Q N LOCAL . AL DISTRICT <br /> UNDERGROUND TANK 1601 E HAZELTON AVE . ,, STOCKTON CA <br /> CLOSURE OR ABANDONMENT Telephone ( 209 ) 468-3420 <br /> 1PPLICITION FOR PERMINBIT/TBMPORIRI CLOSURE OR 1111001XINT IM PLICE OF UEDERGROUNR 11112DOUS SUBSTINCES STORIGE FICILITT <br /> THISR 1T 11PIRBS 10 DIPS FROE TIE 1PPR091L DITL DO 101 11171 11 111 SHIDID IRELS. IYDICITI PERMIT 71PE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACT � PHONE N �. <br /> A <br /> C FACILITY NAME C�C,1) ADDRESS <br /> LCROSS STREET PHONE <br /> I <br /> YOWNERg PHONE I <br /> C CONTRACTOR NAME PHONE <br /> 0 <br /> N CONTRACTOR ADDRESS/()/�) ,> � r G r�L' CA LIC q <br /> T <br /> R LIC CLASS WORK . COMP . Q'6i6doWa( INSURER 2. <br /> A --- — <br /> C FIRE DISTRICTryr ra-zw/G�__ rJ r - <br /> 0 <br /> ERMIT � <br /> fi <br /> LABORATORY NAMEPHONE / <br /> R <br /> SAMPLERS NAME ,/ /� - SAMPLING METHOD <br /> f ' <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID CURRENTLY PREVIOUSLY <br /> E _ <br /> M °�-- -ie a- d TO C '`Y <br /> I � F TO <br /> C TO <br /> A TO <br /> L I LISt ANY EXTRA TANKS ON A SEPERATE SH ET <br /> P =1 M1 ! ! I! I,� Ii I 11 <br /> L ( E ATTAjME WITH C ND I TI ONS) <br /> A PLAN REVIEWERS NAME �J" '\DATE � �� <br /> N <br /> LL <br /> � 9 i ipram, <br /> na <br /> IPPLICINT MUST PERFORM ILL 1011 IM 1CCORDIMCI 11T1 SIM JDiQUIM CDUYTt ORDIM1NCIs, SfIff LIPS, AMD RULIS AMD RECULITIONS <br /> DF TRE w JOIQUIN LOCAL EEILTE DISTRICT. 011IR O1 LICENSED 161111S SICNIfURE CI1f1FIES TMR FOLL011MC: 01 CERTIFI ?BIT <br /> IM 111 PERFORlf11CI OF fig loll F01 11ICE TE15 plulT IS ISSUED, I SMILL NOT IMPLOT IMI PERSON IN SUCK 81MME1 IS TO IECOKE <br /> JUBJECT TO 1ORIMIN'S COMP3NSITIO1 all OF CILIFORNII.' CONT11CIOR'S NINIMC OR JUl-COMTRICTIMG 11011TURI CERTIFIES THE <br /> FOLLOIINC: of CIRTIFf TMIT IN TME PIRFORMINCI OF fig 1081 FOR 11IC1 T11S PERMIT IS ISSUED, I SHALL IMPLOT PERSONS SUBJECT <br /> TO 10RIMIN'J CDXPIN11fION L11S OF C1LI►ORN11. COMPLETE DRIVING OM 1TfICaD PLOT FLIM Silly. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED X TITLE: DATE: <br /> ACCEPTED BY TITLE: DATE: <br /> J A1 ��r ' L' R,►{AyIM]yLri�t r, 1�Y 1' y"5'}p9+!Y'F'?;''�IIIiT!It-�3l��1d�" t <br /> �i <br /> N. w�W4J�Pr I iC.�..�la:�a.�.r:._. - ufiJi J UL4 {� 1 1 1�9 y y M1''F�'C7:,,.�11 Hi•Yf 7nR hy-Ad' .f'u.•rr.. -,•AMM <br />