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APPLICATION FOR PERMi,,w SAN JOAQUIN LOCAL .OoALTH DISTRICT <br /> UNDERGROUND TANK 1601 E HAZELTON AVE. , STOCKTON CA <br /> CLOSURE OR ABANDONMENT Telephone ( 209 ) 968-3920 <br /> IPPLICITI01 FOR PRIMIIIIT/TIMPORIII CLOSURE OR 1811DONNEIT If PLICE Of UNDERGROUND RIYIRDOUS SUBSTINCIS STORIGE FICILITT <br /> TRIS PIBN"IPIRES TO DITS FROM TBE 1PPROTIL D1TI. DO NOT IIITI 11 All SNIDID 1RE1S. INDICIT6 PERMIT TYPE BILON: <br /> V REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACT PHONE <br /> A <br /> C FACILITY NAME j ADDRESS 4,p5--y_ �. <br /> I — <br /> L CROSS STREET1T- PHONE I / <br /> I <br /> T OWNER PHONE I / <br /> Y SFR S/� <br /> C CONTRACTOR NAME �D PHONE I TILJ 372 -2021 <br /> I <br /> O <br /> N CONTRACTOR ADDRESS 1� etx�l . CA LIC I S05O Z7 <br /> T <br /> R LIC CLASS WORK . COMP . #0,i, INSURER <br /> A — <br /> C FIRE DISTRICT PERMIT I <br /> T <br /> 0 LABORATORY NAME ati l PHONE I / <br /> R <br /> SAMPLERS NAME SAMPLING METHOD <br /> C VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> H ID I CURRENTLY J PREVIOUSLY <br /> M I �L�Do �t j 4 TO� N/.4 <br /> I TO <br /> C —TO- <br /> A TO <br /> L LIS ANY EXTRA TANKS ON A SEPERATE SH ET <br /> P <br /> L — 4— (SEE 1A�T C HENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME /Y .� a �� DATE Ab �O <br /> N <br /> i <br /> IPPLICIIT ITS? PERFORM ILL FORS 11 1CCOIDINCE 1ITI Sit ,IOIOUII COUNTY OIDIIIICIS, Stlf/ LIES, IID RULES 11D RICULITIOIS <br /> OF fig S1I JOlIU11 LOUL Illuff DISTRICT. 01111 OR LICENSED 191111S SIGIIfaRE CEItIFIES THE FOLLO/1/C: 11 CERTIFY fall <br /> 11 tit PEEFO:C:.BCI Of 1HI 1011 FOR 1RIC1 fill PIRN1t IS ISSUED, I SI1LL ROT EMPLOY lif PERSON If SOCI HIMME1 1S t0 BECOME <br /> SUBJECT TO ;01"11114 COMPEIS1T101 LITS OF CILIFOR111.1 COIyE1C1OR1S MING OR Sul-CONTRICTING SIGNITUIE CERTIFIES THE <br /> FOLLOIIIG: 11 CERTIFY flit 11 TRI PIRFOININCS OF FEE 1011 FOR //ICI TILS PII111 IS ISSUED, I SHILL EMPLOY PERSONS SUBJECT <br /> TO IORIMIN'S COM1111317101 all OF C1LIPOINII. COMPLETE DRIIIIG 01 11f1CMED PLOT P11N Sally. <br /> CALL FOR ALL NECESSARY INSPECTIONS AT LEAST 98 HOURS IN ADVANCE <br /> SIGNED X p TITLE: DATE: <br /> ACCEPTED BY � 7�n�� TITLE: _ _ DATE: <br /> I!e Ys�.:1F w t !AM#7M1T : ;�':isSr7S?(M1i7.9y1�MN0lS.n:9BIR�JR2'e"" MKtT-..xa�+w.rremunoga�-N :i.; Jnr-..R� <br /> EI 9�°c 70' h sg r�ls Cl <br />