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APPLICATION FOR PEOF SAN JOAQUIN LOC) EALTH DISTRICT <br /> UNDERGROUND TAN 1601 E HAZELTON n . , STOCKTON CA <br /> CLOSURE OR ABANDONMENT Telephone (209 ) 468-3420 D, <br /> IPPLICITIDI FOR PIRMIEEIT/TIMPOIIRY CLOSUIR 01 IBIIDOIMRIT 11 PUCE OF UIDRRGROOID 11111DOUS SUBSTIICIS STORIGI FICILITT <br /> THIS PERMIT IIPIRRS 10 D1TS FROM TAR IPPROTIL D1TI. DO HOT TRITE II III SIID11 19913. IIDICITI PIRMIT TYPE BELOT: <br /> XX REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> F PROJECT CONTACT George Gemellos , I PHONE # 2o_ / 369-1132 <br /> A <br /> C FACILITY NAME IDLEWILD ADDRESS 3049 We HWS* 12 <br /> I <br /> L CROSS STREET DEVRIES RD. PHONE # 209/ 369-1132 <br /> I <br /> TOWNER PHONE 1 209 / 369-1132 <br /> Y George Gemellos , I <br /> C CONTRACTOR NAME George Gemellos, I PHONE # 209 / 369-1132 <br /> 0 <br /> N CONTRACTOR ADDRESS 3049 W. Hwy 12 CA LIC # <br /> T <br /> R LIC CLASS WORK . COMP. # INSURER <br /> A <br /> C FIRE DISTRICT 10loodbridge PERMIT # <br /> T <br /> 0 LABORATORY NAME PHONE # -�� L/ <br /> R <br /> SAMPLERS NAME SAMPLING METHOD <br /> ZPA1JPhUV6Lj <br /> VOLUME CHEMICALS STORED DATES STORED CHEMICALS STORED <br /> CURRENTLY PREVIOUSLY <br /> Leaded gasoline <br /> 550 Ga Leaded gasoline (,a� TOi <br /> AO ' <br /> TO TOLIS ANY EXTRA TANKStASEPEtRA�TESHIET <br /> L (SEE AT.'ACJfNE A PLAN REVIEWERS NAME 9�`- �,✓� FATE 1✓ 1i41( <br /> N <br /> /PPLICIFT MOST PERFORM ILL LORI IH 1CCORDIFCI FIt# SII JOlOUIE COUITY ORDIEIICES, ST1TI LIPS, LED IULIS 1110 RRCULITIOSS <br /> OF THE 311 JOIOU1I LOCIL II/LTI DISTRICT. OFIRR OR LICII3ID 10117'3 SIG/ITORS CIINFIES TBR FOLLOFIIG: 11 CRRTIFI to/T <br /> IE 711 PIRFOIMI►CE OF TRI FORK FOR FEICI THIS PERMIT IS ISSUED, I STILL HOT IMPLO7 llt PEISOI If SUCI MIEIKI IS TO /9COME <br /> SUBJECT TO FOIIMII'S CONPII3lTIOI 1,113 OF CILIFOREII., COITI100R'S MING OR Sul-COHTRICTINC SICIITURI CSITIFIRS THE <br /> FOLLOIREG: 11 CIRTIFY T11T if THE PIRFORMIICI OF TEE FORK FOR FIICI TTI$ PERMIT IS ISSUID, I STILL EMPLOY P91SOIS SUBJECT <br /> TO FORIMII13 COMPI131TIO1 L1►S OF C11,I101111. COMPLETE DIIIING 01 1171CNID PLOT PL11 SRIIT. <br /> CALLOR ALL NECESSARY INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED X ,2,�z TITLE: DATE: <br /> ACCEPTED BY TITLE: ( \ DATE: /" <br />