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t'li:titi�k' t�kYtLlt�t�ti:ti: kiY#(!Yi„itxti�ti� <br /> e APPLICrMU FOR PERMIT w SAN JOIOUIN LOCAL HEALTH DISTRICT.: <br /> t: UIDERGROUVO TAN[ C 1601 E SIZELTON AVE., SfOC[TO! Clg v U <br /> t: CLOSURE OR IIINDONMEIT !: Telephone (2091 168 3120 !: <br /> l:it'R:ti:ti:tisti:ti:tyky.RV. is tvft ti-R :R:ti:R:tyti:ti:ti:ti:tvR:M R:ti:ti:ti:It Ri: OCT 0 3 1989 <br /> APPLICATION FOR PERMANENT/TENPORIRY CLOSURE OR ABAIDONMENT 1N PLACE OF UNDERGROUND 0111RDOUS S6B4YN1M11Sf0186E 19161L101Y <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE IPPROVIL DATE. DO NOT WHITE IN 111 SHADED AREAS. INDICATE I%WHITTI0W1Yrd§ <br /> XX REMOVAL __ TEMPORARY CLOSURE , 1811DONNENT IN PLICI <br /> EPA SITE I CAC000206148 PROJECT CONfICT 0 TELEPHONE I Jack Hill 209 463-2500 <br /> F FACILITY NIKE Kooyman Trucking, Inc. PHONE 1 209 463-2500 <br /> 1 <br /> C ADDRESS 1340 West Charter Way Stockton, California 95205 <br /> I <br /> L CROSS S11191 Argonaut <br /> I <br /> T _OVNEI/OPERITOR Jim Kooyman PRONE 1 209 948-8701 <br /> T <br /> C CONTRICTOR NINE Telic Engineering Corporation PHONE I 209 465-2000 <br /> 0 <br /> 1 COIIRICIOR ADDRESS p 0. Box 2076 Stockton, Ca. 95201 Cl LIC 1 569559 CLASS A Haz-Waste <br /> I <br /> I INSURER Lorenzi Masasso of Stockton <br /> 1 YOH[.COMP.1 WC044690818-89 <br /> C FIRE DISTRICT Stockton PERMIT I/1NSPTI <br /> T <br /> 0 LABORATORY 11ME Canonie PHONE 1 209 983-1340 <br /> R <br /> SIMPLIEG FIRV Canonie SAMPLING METIOD Shovel scoop brass sleve <br /> TIN[ ID I TIS[ SI1E CHEMIC/LS STORID CURRENTL CHEMICALS STORED PREVIOUS6 <br /> T / <br /> 1 39 239_ fi — 2 j22000 <br /> 00 gallon Waste Oil Regular gasoline <br /> 1 J9_ allon Gasoline Regular gasoline <br /> [ 39- <br /> 39- <br /> l9- <br /> LIST ADDITIONAL TIN[ INFORMATION IS NEEDED 01 SEPARITE ?Oil <br /> P PPROVED _APPROVED VITO CONDITIONS _ DISIPPROVED <br /> L SIE ITTICIMSIT YI CONDITIONS) <br /> 1 P61N 16P[EVBRS NAME DILE 4-14W <br /> 1 <br /> IPPLICANf MUS? PERFORM ILL VOR[ 11 ACCORDANCE WITH SAW JOIOUIN COUNTY ORDININCES, STITH LIVS, IND RULES IND REGULITIONS <br /> OF THE SIN JOAOUIN LOCAL HEWN DISTRICT. OYNER OR LICENSED AGENT'S SIGNITURE CERTIFIES THE FOLLOVING: 11 CERTIFY ?HIT <br /> IN THE PERFORMANCE OF THE YORK FOR THICK THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY IVY PERSON IN SUCH KAISER IS TO BECOM <br /> SUBJECT TO YORKER'S COMPENSATION LIVS OF CILIFORIII.' COMTRICIOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY TH11 IN THE PERFORMANCE OF THE VOR[ FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO YORKER'S COMPENSATION LAYS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 90 HOURS IN ADVANCE <br /> SIGNRD- DATE :L'tZ 2, <br /> OFFICE USE ONLY--EH 21 016 12/11 — <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS,S�S55SSSSSSSSSSSSSSSSSFSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SIBEPS I I COMP I LOC CODE DIST COO AMOUNT DUB ANOUNT RCVD CASH RCVD BY 0119 RCVD PERNII 1 <br /> 12 3%(G k�olynml3 C / 3,� � / i-j— /XO 30oi L /0",V/ 7 <br />