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RRRrcRrcRrcrcrcnprcxxrcxWnSxKnWgx�9rcK�97u1WWWWn,ryx;yrcnxrc�t9�W <br /> W APPLICATION FOR PERMI{ W SAN JOAOOIVLOCAL HEALTH DISTRICTN11 <br /> A UNDEj$JNO TANK W IE01 E HAIELTON AVE., STO tI CA 0 <br /> W CLOSUR ABANDONMENT .1 Telekhune (ND 4G8-, <br /> WIW1lA717)!pCW^!;Wf!"!!W!!^7!M">•'WAW W WWWWf!g;!WW!!WW'W!!pf:WWW;YM!!WIFMWWWWIW!iflfiNxx <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X_ REMOVAL ----- TEMPORARY CLOSURE -___ ABANDONMENT 1N PLACE <br /> EPA SITE 1 _ <br /> CAC-000-147893 PROJECT CONTACT 1 TELEPHONE 1 <br /> F FACILITY NAME Geor e Je son 714 385-5795 <br /> A Laura Scudders PHONE 1 (209) 835-6300 <br /> C ADDRESS 100 ValPico Road, Tracy,cy, California <br /> L CROSS STREET Trac, Boulevard <br /> I <br /> T OWNER/OPEP,ATOP, same as above PHONE p <br /> Y same as above <br /> C CONTRACTOR NAME Precision industries, Inc. PHONE 1 <br /> O (209) 462-9911 <br /> N CONTRACTOR ADDRESS 1041 S. Pershinc Ave., Stockton CA LIC 1 <br /> 1 467293 CLASSA & B <br /> R INSURER, Ohio casualty <br /> A WORK.COMP.1 y (g9)400-96-87 <br /> C FIRE DISTRICT Tracy Fire <br /> r PERMIT 1/INSPTR <br /> 0 LABORATORY NAMERoy F Weston PHONE 1 <br /> R (209) 957-3405 <br /> SAMPLING FIRM* Rod, F. Weston SAMPLING METHOD <br /> brass tube <br /> T TANK IO 1 TANK SIZE ICHEMICALS STORED CURRENTLY CHEMICALS STOPED PREVIOUSLY <br /> A 39 _ tlf23 �} .3 _"-,00e- (novo _ diesel fuel _ diesel fuel <br /> N 39----1-se —__p_/_-_- <br /> 2,000 — unleaded asoline in <br /> K, 39 <br /> 39- <br /> --------------------------- <br /> 9 <br /> ------------------------ --- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> u r <br /> nrn <br /> P __-- APPROVED ___APPROVED WITH CONDITIONS <br /> L DISAPPROVED <br /> - (SEE ATTACNME WITH CON TIONS) <br /> A PLAN REVIEWERS NAME __-__-_ <br /> N - - - - DATE - - <br /> 9 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER, OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: °I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORT; FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER, AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING, OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING,: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED <br /> - --------------------------------------------------------------------------DATE --- <br /> OFFICE USE ONLY <br /> ffiifffffiffffiffffffiffifft;fffffffiffffiffftfffiffffffifffifffiffiffifffftiiffffffffffffffffffffffffifffffffifffffffffff <br /> SWEEPS 1 I COMP 1 'LOC CODE •DIST CODE' AMOUNT DUE AMOUNT RCVD ' C1;1/CASH RCVD BY DATE RCVD i PERMIT 1 <br />