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t:It'a IVal 1:ft:tvtttR III:IV tZ R: tIII:ti R:R:It:till.It R It: ttn:tl: <br /> w APPLICIME FOR PERMIT a SAM JOAQUIN LOCAL HEALTH D�1RICTp: <br /> t: UIDERGROUWD TANK t: 1601 E HIZELTOY AVB., ST04up ell <br /> t CLOSURE OR 11INDONMBYT t: TelepNooe I2011 168-3d2 /pC� eo <br /> t:it:R:It:IV It tyIVIt'4 tln:l:tt I%:III:It.R:It'A:ttIVIt:IVR:R:R:It It:tt:t <br /> APPLICATION FOR PBRMANINT/TBMPORIRT CLOSURE OR IBAIDONMENT IN PLACE OF UNDERGROUND FACILITY <br /> THIS PERMIT EXPIRES 90 DIPS FROM THE APPROVAL DATE, DO NOT 11116 IV III SIIADII AREAS. INDICAWF,]Ifl, H TYPE 18LOW: <br /> REMOVAL ._ TEMPORARY CLOSURE — ABANDONMENT IN PLACE <br /> SFS��ry <br /> EPA SITE � — PROJECT COITICT i TELEPHONE 1 - <br /> Butch Munson 209-943-038 <br /> 4 <br /> CAC000546192 <br /> P FACILITY NAME PHONE I <br /> I Nor Cal Beverage (209) 943-0381 <br /> C ADDRESS 1800 "E" Fremont Street <br /> 1 Stockton CA 95205 <br /> L CROSS STREET <br /> I Wilson Wa _ <br /> 1 OWNER/OPERATOR PHONE 1 <br /> 1 <br /> C CONTRACTOR NAME placer Tractor Service PHONE 1 (916). 652-55357- <br /> 0 - <br /> 1 CONTACTOR IDDRISSp.O. Box 170 Loomis, CA 95650 CA LIC I 440591 CLASS A <br /> T <br /> I INSURER Motherlode Insurance YORK.COMP.1 W0703812 <br /> C FIRE DISTRICT City Fire Prevention PERMIT 1/INSP?Paiting for approved copy <br /> T Eieding to 4 N PI perado pe, Olivia <br /> 0 LABORATORY Y1M6 Alpha Labs PHOtlB I <br /> R ( 707) 468-0401 <br /> SAMPLING FIRM' SAMPLING METYOD <br /> DIWYWNNY "WtlNtW _ As per County's Method <br /> TIME ID I ?III SITE CHEMICALS STORED CURRIATLI CHEMICALS STORED PRIVIOUS6 <br /> t <br /> 10,000 Reg. Gas <br /> I non Unleaded <br /> I <br /> 39- Jin lon u leaded <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FOIN <br /> NNWYNRRNWYWWNWYtiONWYWWNWWYWlWWtWYO p.yy�u: nynm!i WYYCW9tlDWtlNNMtlYY9t11LJtlMJi'IIJLYUDCWUJYW7HW11WYtWNI <br /> P APPROVED _APPROVED WITH CONDITIONS DISAPPROVED <br /> L (SIBTtICIMEYT PITH CONDITIONS) <br /> ! PLAN 111MVIRS NINE Oft— -1—RF—VE'/v, — — _DATE_1�014ep <br /> Y <br /> APPLICANT MUST PERFORM ILL RORK 11 ACCORDANCE WITH SAM JOAQUIN COUNTY ORDIYIYCES, STATE LAYS, AND RULES IND RICOL11IONS <br /> OF THE SAI JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SI'CN11VR6 CERTIFIES THE FOLLOWING: 'I CERTIFY TWIT <br /> IN THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I S41LL NOT EMPLOY ANY PERSON IN SUCH WINNER IS TO 81COM <br /> SUBJECT TO YORKER'S COMPENSATION L/YS OF CALIFORNIA.' CONTRICTOR'S HIRING OR SUBCONTRACTING SICNITURE CERTIFIES THE <br /> FOLLOWINC: 'I CERTIFY THAT 11 THE PERFORMANCE OF 111E PORI FOR YNICH THIS PERMIT 13 ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> 10 YORKER'S COMPENSATION LIES OF CILIFORIIA. <br /> CALL G' INSP IONS AT <br /> HAA <br /> ,LEAST 40 OURS IN ADVNN,C,E, / Q� <br /> SIGNED `a=47� (�"�--- <br /> OFFICE USE ONLY-811 11 016 11/11 <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSH'SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSlSSSSSSISSSS <br /> W6 PS I-��M I LOC COD�DIST COD AMOUNT DUHII AMOUNT RCVD I CKI/CASH I-- RCFD-BY -I- Dd18-RCVD -I PERMIT 1 <br /> J - <br />