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• <br />�:`• APPLICATION FOR PERMIT <br />UNDERGROUND TANK <br />CLOSURE OR ABANDONMENT <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />0 <br />N <br />T <br />R <br />A <br />T <br />R <br />H <br />E <br />M <br />I <br />A <br />L <br />P <br />L <br />A <br />N <br />• <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E HAZELTON AVE., STOCKTON CA <br />Telephone (209) 468-3420 <br />APPLICATION FOR PlININENT/TiNPOILIT CLOSURE OR 4I1DOWNINT IM PLICR Of UNDERGROUND HAZARDOUS SUBSTINCES STORIGE FACILITY <br />THIS PIRMIT IZPIRES 1.0 D1TS 1R0N THE APPROVAL D1TI. DO NOT WRITI 11 111 SHIDYD AREAS. INDICATE PERMIT TYPE BELOW: <br />_ REMOVAL. TEMPORARY CLOSURE ABANDONMENT IN PLACE <br />PROJECT CONTACT (LR -K <br />PHONE 0 `�/ 64G-4CO3 <br />FACILITY NAME -5-TA-rml ADDRESS 232-o i j. ELDozAzt,o S-(OC*f—,oi.j <br />CROSS STREET n.1�,br��5 PHONE 02-0 / 943- 1311 <br />OWNER PHONE # AL5 / G3(0- N11 <br />L—L-- C>► <br />CONTRACTOR NAME SGE IINI-+4� i -4s -r PHONE <br />CONTRACTOR ADDRESS <br />LIC CLASS <br />WORK. COMP. # <br />FIRE DISTRICT SA,t _..joa qui t� <br />CA LIC 0 <br />INSURER <br />PERMIT # <br />LABORATORY NAME 6-6-t, c>dI5 L,&,E> I PHONE # ZC--9 /_ 903 -1M0 <br />SAMPLERS .NAME C-AOOr�iJ; (-1-,B. : SAMPLING METHOD c4RAL3 E Hap <br />ppin <br />FROM <br />VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br />ID # CURRENTLY PREVIOUSLY <br />0 <br />�o �r-1 t1 l I).Li', TO <br />oar Co I (D8 TO Pn � <br />CO0 r'ta i Ki t _Lcj-7() TO Pea5at i IS <br />TO— <br />LIST ANY EXTRA TANKS ON A SEPERATE SHEET <br />7— <br />TS, E A <br />PLAN REVIEWERS NAME f <br />(W UH CONDITIONS) <br />DATE - <br />IPPLICIII NDSt PIRFORN ILL 1ORC IN 1CCORDINCE will 11N JO1QUIl COUNfP ORDININCIS, Still LAWS, IND RULES AND R1GUL1tIONS <br />OF THE in JOIQUIN LOCAL 11ui1 D1I11ICT. ONNIR OR LICINSID 191111S SIGNITURE C1I1IFIE1 TNR FOLLOWING: 'I CERTIPI THIT <br />1N fig PIRFORIbINCE OF fig WORM FOR Nl1CN ?IIJ PERNIf IS ISSUID, I STILL NOT ENPLOT In PERSON IN SUCK NINNER AS t0 9ECOXI <br />SU6JICt TO MORININ'S CONPINSATION LAMS OF CILIPORNII.' COMIRICTOR'S NIRING OR Jul-CONtRICTING SIGNATURE CERTIPIIS THE <br />FOLLOWING: 11 CIRTIFT tilt IN TRI PERFORN1NCl OF fig MOI, FOR fllCl TRIS PERNIf IS ISSUED, I SHILL BNPLOY PERSONS SUBJECT <br />TO NORININ'S COMPEIS1T101 L11S Ol CALIFORNII. CONPLITI DIIMING of IffICHID PLOT PLAN SHIII. <br />CALL R A C N ESSARY INSPECTLONS AT LEAST 48 HOURS IN ADVANCE <br />SIGNED TITLE: FcV 54(�t j � DATE: 1 -L- Z-9 -Ei <br />ACCEPTED -BY TITLE• DATE: <br />to I <br />sYuwlrew w.. .........,N,....,.,,...,,,..... . 9rt.•rtr N�li�l liLl� �r... <br />