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r APPLICATION FOR PEE, SAN JOAQUIN LOCA, EALTH DISTRICT <br /> UNDERGROUND TANK 1601 E HAZELTON A .E. , STOCKTON CA <br /> CLOSURE OR ABANDONMENT Telephone (209 ) 968-3420 <br /> APPLICATION FOR PERN11B1T/TSMPOl11T CLOSURI 01 1811DONMENT 11 PLICS OF UNDERCROUID RAIIRDOUS SURSTINCIS STORAGE FICILITT <br /> III$ PIRMIT EIPIRES 70 DITS PION TNI IPPIOTIL DAYS. DO HOT FRITI IN III SNIDID IRRIS. 11DICITI PIENIT TIPS BILOE: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> Pf} #e-AL-78 zad 00 3 Z/ <br /> F PROJECT CONTACT <br /> A Q� D���S Pm� PHONE 1 p VC91-e2864 <br /> i� <br /> I FACILITY NAME,i,,_ ADDRESS / T <br /> L CROSS STREET <br /> � 90PHONE 64 /_ _9e3�'08G4 <br /> I <br /> T OWNER PHONE 1 <br /> Y <br /> C CONTRACTOR NAME _i� /� PHONE I -2L? .�!/_,•S!-R�g 3- <br /> 0 K <br /> N CONTRACTOR ADDRESSCA LIC I <br /> T D %-' <br /> R LIC CLASS WORK . COMP. 1 INSURER <br /> A <br /> C FIRE DISTRICT a`j.�p, PERMIT I <br /> T <br /> 0 LABORATORY NAME � � PHONE I <br /> R <br /> SAMPLERS NAME C Cl�Oxt C, SAMPLING METHOD <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID 1 CURRENTLY PREVIOUSLY <br /> E <br /> M D/< /�iJ�C /96lo TOt��a� <br /> I TO <br /> C TO <br /> ATO <br /> L LIS ANY EXTRA TANKS Oh A SEPERATE SH ET <br /> P <br /> L (SEE AC NT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME T 1 _ DATE <br /> N <br /> 1PPLICIIT MUST PERFORM ILL LORI 11 1CCORDINCS IITB SII JOlOU11 COUITT OROIIl1CIS, $TITI LAPS, UD RULIS 1N0 RECULITIOIS <br /> DP TBI 311 JOIOUII LOCAL IIILTI DISTRICT. DINER OR LICIISID ICIIT'S SICIITURE CEITIFIES TBR FOLLOWING: 'I CIRNFI MIT <br /> II THE PERFORM/CE OP THE TORI FOR IH1Cl THIS PIRNIT IS ISSUED, I STILL HOT ENPLOT III PIISOI II SUCH N11HIR IS TO BECOME <br /> SUBJECT TO IORINII'S COHPIIS1TI01 LITS OF CILIPORNII.' COITRlCfOR'S I111MG OR SHA-CONTRICTING SICIITURE CRITIFIES THE <br /> POLLOVIC: 11 CIRTI►T TILT 11 THE PIRFOININCI Of THS WORT FOR WINCE TILS PERNIT IS ISSUED, I SE/LL INPUT PERSOIS SUNICT <br /> TO IOII1/1'S CONPSISITIO► LIWS 01 C10101111. COIPLITI DI/1116 01 ITT/CHID PLOT PL11 11111. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT <br /> LEAST 98 HOURS IN ADVANCE <br /> SIGNED Xld -r!� h�s� TI TLE�//t o/A�CDATE: /.L'OxQ'8B <br /> ACCEPTED BY TITLE: DATE: <br /> � ITEDI I I I � <br />