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APPLICATION FOR PER <br />UNDERGROUND TANK <br />CLOSURE OR ABANDONMENT <br />SAN JOAQUIN LOCAL WEALTH DISTRICT <br />1601 E HAZELTON AVE., STOCKTON CA <br />Telephone (209) 468-3420 <br />1PPLIC/iI01 POJt=?1111I1IT/TBNPOYIti CLOSURE OR 1811001HENT IM PL1CS OF UNDBQCROUID lit1QDOUS SUBSTIECIS STORKS FICILitf <br />THIS PIRMIT41PIRRS SD DIPS FROM Tit IPPROTIL BITE. DO NOT TRITE 11 111 Ss1DID IREIS. IIDICITI PERMIT TYPE BILOY: <br />REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br />FF! I PROJECT CONTACT PHONE # <br />A <br />C <br />I <br />I <br />T <br />Y <br />C <br />0 <br />N <br />T <br />A <br />C <br />T <br />0 <br />R <br />C <br />H <br />E <br />M <br />C <br />A <br />L <br />FACILITY NAME -I- ADDRESS <br />CROSS STREET PHONE #�,J <br />OWNER / �)�`� %�/ _ PHONE # <br />CONTRACTOR NAME <br />CONTRACTOR ADDRESS <br />C . <br />LIC CLASS <br />C> <br />PHONE #'�' <br />CA LIC # <br />WORK.' <br />COMP. # INSURER :-<c - <br />FIRE DISTRICT;/ �i5 fPERMIT # <br />LABORATORY NAME PHONE <br />SAMPLERS NAME SAMPLING METHOD <br />VOLUME CHEMICALS STORED DATES STORED <br />ID # CURRENTLY <br />TO <br />TO <br />TO <br />LIS ANY EXTRA TANKS ON A SEPERATE SH: <br />CHEMICALS STORED <br />PREVIOUSLY <br />T <br />DI v <br />L I(SEE ATTACHMENT WITH CONDITIONS) <br />A PLAN REVIEWERS NAME DATE <br />N <br />P <br />IPPLIC1It Nut PERFORM ILL FORK I1 ICCOROINCE fill SI1 J0109I1 COUNTY O20I111CIS, Stiff LIPS, 1ND RULES AND RICULITIONS <br />OF THE SII JOIQUII LOCIL II1LTs DISTRICT. OYIER 09 LICENSED 16IIT'S SICIITURR CEtfIFIIS Til FOLLOYIIC: "I CERTIFf TH1t <br />11 fog PERFORWCE OF TER YORE FOR fifes fli$ PIRNIf IS ISSUED, I SKILL NOT EMPLOY 1NY PERSON IN SUCH M1NMER 1S t0 IECONS <br />SUBJECT TO 101LN1IIS COMPINSITI01 Lifs OF C1LIF02111.' COIfRICfOR'S TIRING OR SUE-CONfI1Cfl1C SICINURE CERtIFIES THE <br />FOLLOYIIG: 'I CERTIFY flit IN In PIRFORNINCE OF THE YORK FOR YRICH TSI$ PERNIT IS ISSUED, I $111L EMPLOY PERSONS SUBJECT <br />TO NORIMII'S CONPIISITIOI LEY$ OF CILIFORIII. COMPLETE 11111110 ON IffICHED PLOT ?LIN $HBIt. <br />CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br />SIGNED X TITLE• DATE: <br />ACCEPTED BY TITLE: DATE: <br />