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I: UNDERGROUND TANK �; 1601 E HAZELTON AVE., STOCKTON CAS <br /> CLOSURE ABANDONMENT t; Telephone (209) 468-3 I; <br /> ?::???:�Y.�Y.:?�:?:�Y.:?�:?�?:?7:?: <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY t <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br /> REMOVAL _____ TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br /> EPA SITE I PROJECT CONTACT f TELEPHONE 1 Western Meter Ser- <br /> - vice, Inc. _ ,; <br /> F FACILITY NAME PHONE # <br /> A St ._ Joseohs Hospital_-_ 209 948-6124 _ <br /> C ADDRESS <br /> I 1800 North California Street Stockton, CA <br /> L CROSS STREET V, <br /> 1 <br /> Hardin <br /> T OUNER/OPERATOR PHONE I a <br /> Y <br /> Roek Brothers Construction (209 ) 464-8344 <br /> C CONTRACTOR NAME -------------- _-� PHONE t <br /> O W rh Meter ServiceInc. 209 948-6124 <br /> 2735 Teepee Drive , Ste. E <br /> N CONTRACTOR ADDRESS p CA LIC I CLASS <br /> T Stockton,CA 95205 414051 C-61-040 <br /> RtFIRE <br /> R <br /> A _ _— WORK.COMP.# NWC) 49255 <br /> CISTRICT PERMIT #/INSPTR <br /> 0TORY NAME PHONE t <br /> R 209 983-1340 <br /> G NAME <br /> SAMPLING METHOD Soil sample to be taken 5Y` <br /> et in..,i <br /> TANK ID I TANK SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL nat 1-7 <br /> A 39-__14D 3(2_ O --- i 1 <br /> K 39 N, <br /> -------------------------- - <br /> 39--------------------------- <br /> jAPL:AMXREV:1EWERS <br /> - `3 <br /> ------------------------ <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM 6f y <br /> a- <br /> APPROVED APPROVEp WITH CONDITIONS DISAPPROVED <br /> ) <br /> ( EE ATT HMENT WITH CONDITIONS) / Q <br /> NAME ---- DATE- / <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOADUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS 9- <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: Of CERTIFY THAT + <br /> f <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, [ SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECO <br /> 21s <br /> SUBJECT TO YORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, l SHALL EMPLOY PERSONS SUBJEC )v <br /> TO YORKER'S COMPENSATION LAWS OF CALIFORNIA. :,,_ <br /> CALL FOR INSP CTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED�_�__ M_-- - `- J Wes Dubose DATE 12/27/8 <br /> --------------- ------ <br /> SWEEPS <br /> ^s' <br /> OffZCE OSE OYLY--EN 13 016 12/88 - - - -- - - - - - - ------ --- ------ j <br /> fffifffiffSffffffffffffffffffffffiftffffffffffiffffifffffftffffffffffffffffffffftffffttfttffffffffffffffftfffffffffffftft <br /> SIWEPS t COMP t LOC CODE JOIST CODE AMOUNT DUE AMOUNT RCVD CKI/CASH L RCVD BY I DATE RCVD PERMIT f y <br />