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APPLICATION FOR PERMIT SAN JOA66fW'LOCAL HEALTH.-6?r T RICTv <br /> UNDER NO TANK <br /> IGOI E HAZELTON AVE., STOG,,,A CA <br /> CLOSURE*ABANDONMENT Telephone (209) 468-3420 <br /> 2..fftl 2 ft.: <br /> !,U <br /> 'APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> 'THIS,PERMIT EXPIRES 90 DAYS FRO E 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> THE APPROVAL DATE. <br /> R <br /> EMOVAL ----- TEMPORARY CLOSURE .... ABANDONMENT IN PLACE <br /> 4, r-- <br /> EPA'SITE I CAC000551952 PROJECT CONTACT & TELEPHONE I <br /> F FACILITY <br /> NAME Kingdon air Park PHONE 1 209-466-9820 <br /> C -ADDRESS <br /> 12145 N. Devries Road/ Lodi , Ca 95242 <br /> L: 'CROSS STREET <br /> Armstrong road <br /> 'V OVNERIOPERATOR <br /> Albert To Tian PHONE I <br /> Y, <br /> 209-466-9820 <br /> -------- ------ <br /> 'Cl '6ii"ICTOR WE Western Meter Service , Inc PHONE I <br /> 209-948-6124 <br /> ''COXTRACTOR ADDRESS 2735 Teepee Drive, Suite E CA LIC 1 4051 CLASS C61 'D­� <br /> T S <br /> .-I-NSURERGolden Eagle Insurance WORK.COMPANWE110296 <br /> ---------------- <br /> X FIRE DISTRICT <br /> T, San Josquin County PERMIT 11INSPTR <br /> -0- LABORATORY )LAM 7 <br /> PHONE 1 209-667-6463 <br /> SAKKINGFIRMI ETS Environmental SAMPLING METHOD Soil excaklation by backho <br /> s a M p I <br /> r TANK ID I <br /> ass CHEMICALS STORED CURRENTL CHEMICALS STORED pRfVIOUSL t <br /> u ii� <br /> I <br /> 39-* <br /> - 9-if Liol- I Q a0c) <br /> ----------------- <br /> --—31- <br /> - -- <br /> —---- --------- <br /> —----- -------- <br /> -------------- - <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FOR <br /> APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> LE ATTACHMENT WITH CONDITIONS) <br /> PLAN REVIERERS NAME <br /> DATE <br /> -------- ............ <br /> a. <br /> --- - ---------------------- ------------------ <br /> "APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS <br /> JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: <br /> %I CERTIFY THAT <br /> If-.THE'PfRFORhAXCE 0, THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECO <br /> .'_tU0JECfTO'W=IS COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> fOILOW <br /> COMPENSATION LAWS OF CALIFORNIA. <br /> TO WORKER'S I)1fi-:?fCERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> CALL <br /> FOR INSPECTIONS I CTIONS AT LEAST 4e HOURS IN ADVANCE <br /> ------;+-- ---------------------------- DATE <br /> ISE DILY- ER 23 0j6 12188 <br /> ----- 'A <br /> COMP I LOC CODE DIST CODE J AMOUNT DUE AMO I UNT RCVD <br /> CK11CASH RCVD By, <br /> DATE RCVD PERMIT.f <br />