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L&Q:":tit: <br /> j: APPLICATW PERMIT k: SAN JOAQUIN LOCAL HEALTH DIWCT <br /> t: UNDERGRMD TANK 1601 f HAZELTON AVE., STOCrTON CA 457Aic <br /> t: CLOSURE OR AgANDONMENTTelephone (209) 468-3420 <br /> 2.2.12 <br /> APPLICATION FOR PERMANENT/TEiPORARY CLOSURE OR ABANDONMENT IN PLACE OF <br /> .12 <br /> UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT ErPIRES SO 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 ; C PROJECT CONTACT & 7ELEPHO?4� I <br /> 000 15q 157 SA <br /> FACILiTY NAM: T <br /> JOHN RAY CO. INC.' PHONE 1 209 <br /> ADDRESS <br /> 2249 Waterloo Road Stkn. Ca. 95205 <br /> CROSS STREET <br /> Cherokee Ruad FEB 8 <br /> OWNERIOPEPATOP <br /> PHONE i ENVIRONMENTAL HEALTH <br /> John Ray Co. Inc, (209) 466—MMIT/SERVICES <br /> C i CONTRACTOR NAME <br /> I Stockton Contracting Croup, Inc. PHONE 1 (209) 462-5082 <br /> N CONTRACTOR ADDRESSIOOO N. Union Street Stkn. Ca. <br /> T CA LIC 1 528156 CLASS. A <br /> R INSURER ON FILE <br /> WORK.COMP.# <br /> A ON FILE <br /> C FIRE DISTRICT Stockton PERMIT IJINSPTR — <br /> T, Pending 1-7 <br /> 0 LABORATORY NAXECanonie Environmental <br /> R PHONE # (209) 983-1340 <br /> SAMPLING FIRM* Canonie Environmental SAMPLING METHOD Hand / Brass Tube <br /> TANK ID I <br /> T TANK SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSLI <br /> A 39-_I_'757��::I�Q_j 29000 <br /> N 39- 2 000 Unleaded Gas <br /> ------ Regular Gas <br /> ------ --- 2,000 Diesel G s <br /> 39- <br /> 39--------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P <br /> L APPROVED -__APPROVED WITH co71x ---- DISAPPROVED <br /> REYIE�ERS NAME <br /> A PLAN (SE ATTACHMENT WITH CONDITIONS) <br /> -------------------- ------------ <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 <br /> SIGNATURE CE <br /> I IN THE PERFORMANCE OF THE WORK Fop RTIFIES THE FOLLOWING: 'I CERTIFY THATI <br /> , WH;C,,H THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <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 SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 46 HOURS IN ADVANCE <br /> ------------------------------------------------------DATE <br /> FICI SE ONLY <br /> fffiffff <br /> SWEEPS i MP I LOC CODE DST CODE <br /> 0 A UNT DUE AMOUNT RCVD CKIYCAS8 RCVD BY DATE RCVDffisffPERMITf#Sf <br />