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LY t:v-ti:ti:ff tT t-1:t-t7t,ft ty,ft,R.ty-R.ti:tv ft Vr-ti:k�tk-ti:M R:ti:R,ti <br /> APPLICATION PERMIT SIN JOAQUIN LOCAL HEALTH DI9TR1wf*t-, <br /> UNDIRGROUNO TANI 1601 1 HAZELTOK AYH., STOCKTOX CAV. <br /> CLOSURE OR ABANDONMENT t: Telephone (2011 468-3120 r- <br /> V ff kl:1:r-R!R-'ff VY t:v.t:t:tiv-LI:tv-ft.t-1:tV-t-1:it:LY R,R.tv.tv.L:V-R,RE ty.t7v.R:ff.R:ty.R: <br /> APPLICATION FOR PRRKANEXT/TEKPORIRT CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE 19 111 SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL X— TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> B i 11 Channel ] <br /> PROJECT CONTACT i TELEPHONE I <br /> EPA SITS I CAC 0.00180229 209 833-3507 <br /> 833-3507 <br /> F FACILITT MANZ Chase Chevrolet —[PHONE 1 (209) 956-7622 <br /> A <br /> C ADDRESS 423 North Madison, Stockton, CA 95361 <br /> L CROSS STREET Frem' ont <br /> I <br /> T OVMER/OPERATOR Auto Investments PHONE I <br /> Y c/o Gerald Sperry (209) 474-1822 <br /> C CONTRACTOR MAN[ Tell,c FZgj nq9d-P-_g� P�-- PHONE 1 (209) 465-5886 <br /> 0 <br /> I CONTRACTOR ADDRESS P.O. Box 588, Stockton 95201 CA LIC 1 505704 CLASS A <br /> 7 — <br /> R INSURER CNA VORK.COMP.1 WC-415 <br /> C FIRE DISTRICT City of Stockton PERMIT lIINSPTR See Letter <br /> 0 LABORATORY NAME B—'iC-:-.- Labortories PHONE 1 (805) 327-4911 <br /> R <br /> SAMPLING FIRMI W at e r tl o r k Corp <br /> SAMPLING METHOD Angle Boring/Drive Samples <br /> --- 91��99ifp�flRN�I1DlQI6OII�IUnJ�IMIIlDBl1111111! <br /> TANI 19 1 ?INK SIZE CHEMICALS STORED CURRENTLI CHEMICALS STORED PREVIOUSL) <br /> T <br /> A 1,000 gallon None Diesel <br /> 1 500 gallon one used I I <br /> 1 000_2al I on— None Used 0 i 1 <br /> 33- <br /> LIST ADDITIONAL TANI INFORMATION AS NEEDED 01 SEPARATE FORK <br /> P APPROVED _APPROVED WITH CONDITIONS DISAPPROVED <br /> L (SRI ITTiCHKENT WITH COKDITIOIS) <br /> A PLAN REVIEWERS NAME DATE A <br /> u, <br /> IPPLIC48T MUST PERFORM ALL YORK 11 ACCORDANCE WITH SIN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. 011ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> 11 THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SKILL 107 EXPLOT ANY PERSON IN SUCH MANNER AS 70 BECOMI <br /> SUBJECT TO YORKER'S COMPENSATION LAYS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY THAT IN THE PERFORMANCE OF SHE WORK FOR WHICH THIS pXjKj? 13 ISSUED, I SHALL EMPLOY PERSONS SU8jRC1 <br /> TO YORKER'S COMPENSITION;,LAVS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED <br /> OFFICE USE ONLY--EN 23 046 12131 <br /> SWEEPS I -COMP I LOC CODE JOIST CODI AMOUNT DUEAMOUNT RCVD CXI/CAS9 RCVD .BY DATE RCVD I PERMIT I <br />