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t it:it:R:ti:tt.ttrotl'ttt.tY tt:ti:L't:tt:tt.t"t!tt.tt:tt:tj�l't.tis tt.R:Nf R-'LlOff <br /> e APPLICIIIOY FOR PERMIT V. SAN JOAQUIN LOCAL HEALTH D[SfRICTt: <br /> t: UNDERGROUND TANK t: 1601 E HAKELTON AVB., STOCKTON CIt <br /> t. CLOSURE OR IBINDONMEIT t: Telephone (209) 468-3420 g <br /> ttttttt'CYitItttkt'tttit:ftttMR 1 1:L'%ttCYttkt'ttttCtttkl'LtttktttCtkt <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSUIW OR ABANDONMENT IN PLACE OF UNDERGROUND HIKIRDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EMPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT IR1T8 IN III SHADED AREAS. INDICATE PERMIT TYPE RRLOW: <br /> X REMOVAL TEMPORARY CLOSURE — ABANDONMENT IN PLACE <br /> EPA SITS IC/,/-- �jjpZ PROJECT CONtICT A TELEPHONE I Spence Poore <br /> F FACILITY AHONE 1 <br /> East Bay Municipal Utility Di iP. (209) 463-2463 <br /> A NAME <br /> 1 ADDRESS West Main Street Stockton, CA <br /> L CROSS STRWKf Los Angeles NOV_? n <br /> I ty <br /> T OWNER/OPERATOR PHONE 1 a <br /> Y (209) 463-2463 ERlvi/,i <br /> _Spence Poore__ k -- <br /> C CONTRACTOR NAME Cottle Engineering PHONE 1 (415) 754-9935 <br /> 0 <br /> N CONTRACTOR ADDRESS P.O. Box 163 Antioch, CA CA LIC 1 481444 CLASS A <br /> R INSURER Fairmont Insurance WORK.COMP.ITra sn america Workers' omp. <br /> C FIRE DISTRICT Stockton Fire < 45 PERMIT I/INSPTR #12829 <br /> T <br /> 0 LABORATORY WAMB xP•rae�naT sj I/� �Lt,463 PHONE 1 (415) 783-6960 <br /> R <br /> SAMPLING FIRM' TraPe a_ nalT. $IMPLING MSTNODone at each end of tank <br /> — WNkNNWDWNWWWIWNNWWtlDL'WiWWWWIIWLIWttIIIIIWiNRiIWItlW911 <br /> TANK ID 1 TANK 5118 CIIBMICILS STORED CURRENTLI CHEMICALS STORED PRNV[OUSL <br /> T <br /> 139--- 1,000 unleaded asoli e <br /> N 39--1���=� - 1,000 diesel <br /> K 39- <br /> ]I--- <br /> LIST <br /> 9-]9-_ LIST IDDITIONIL TANK INFORHIIIOK AS NEEDED OW SEPARATE FORM <br /> NRDRWWIWtWVWWIIBNWIWiNIWWWWWDDtlNIWWNIIIYDIDIUIIWIW�Wwit",IIIW11tlIiILYDWW111DIIIlA'1WC9NWIIIWIi!1WWIIIWuiIDINRUDtl'W'WI!9WUWWNII,gWYY7"d'Jl•LliuUulW'2SIIWDIWAIIDWL'tlIINItiCWUWIRIIIDIIIWWdU;W'WIIWIIq!IWWWtlIJIIIIGWIWWDWINND: <br /> P APPROVED -IPPROVED WITH CONDITIONS __- DISAPPROVED <br /> L (S" ITTACIIMENT WITH C040[T101S) <br /> PLAN REVIEWERS NAME fi i.'';.., _ _ _-BITE �ITj/�5 NII <br /> -- ---r------- <br /> M <br /> DYWINNIWYWNMLMWIWMWIWW�tltlRYtIYNDWR�tl�'LWWWIR - 'IDWtlYt'WYW � 'YWDWWWWhJ''INDMRIIRBYDRtlIYWDJIDW�INMDtN10RWWRRDIDW <br /> APPLICANT MUST PERFORM ILL YORK IN ACCORDANCE WITH SIN JOAQUIN COUNTY ORDINANCES, STATE LAYS, AND RULES IND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNITURR CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHILL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECON <br /> SUBJECT 10 YORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRICTOVS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THI? II THE PERFORMANCE OF ?118 YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUOJEC <br /> TO YORKER'S COMPENSATION LAWS OF CILIFORNII. <br /> CALL FOR INS);,+ECTIONS $T LE T 40 HOURS IN ADVANCE <br /> SIGNED .�/ ) /� ---------- DAtE- '_�--- <br /> OFFICE USE ONLY--BII� 12111 <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSs'SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SVIEPS-II COMP I -I LOC CODE 10151 CODEj -AMOUNT OUR - AMOUNT RCVD -CKI/CIS11 I-RCVD BY-I- DITB RCVD I PERMIT <br />