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Ft:rit' FF0:0:t ti:tfi--W.R.R:tvt�.t.".ti: t;-tVt#*.tirR:ti: ti: 0: ti: tv��ti: <br />APPLIC1TI01 OR PERMIT SIN JOAQUIN LOCAL HEALTH DIStxICTk: <br />t: UNDERGROUND ?AHK t; 1601 B HIZELTON IVB., STOCKTON Clt: <br />t: CLOSURR OR IIINDOMNENT t; Telephone 1209) 168-3121 t:' <br />tt�R;ki:tv.t:r.0:ti.,tv.k:r. fifi.tVt:rlti: t t t tv. ft- R.R:k1*R:t:r.R.ff. ti.,t:r.R.,k:r- :kj: <br />APPLICATION FOR PBRMINBNT/TBMPORIRT CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTI UgR4ggqgI?Y <br />?HIS PERMIT EKPIRBS 90 DAYS FROM THE APPROVAL DATR. DO NOT III?R IN 111 SHADED IREAS. INDICATE PERMIT TYPE IBLOW: <br />XREMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE EWRONMEM HEALTH <br />---- ---- --- PERWISERVICES <br />Bea stTE t CAL p� any p i �� PROJRCT CONTICT i TELEPHONE I MEL BOKIDES <br />..-1209) 941-20]1 <br />F FACILITY NIMR MEL BOKIDES PETROLEUM, CARDLOCK #2E8011 <br />1 <br />: <br />C IDDRBSS 983 MOFFAT BLVD. MMUBCA, CA. <br />I <br />L CROSS ST1111 COWELL <br />1 -- <br />T OWNER/OPBRITOR PHONE 1 <br />1 MEL BOKIDES PETROLEUM (209) 943-2011 <br />C CONTRACTOR NINE PRECISION INDUSTRIES PHONE 1 209 462 <br />0 <br />N COITRICTOR IDDRBSS 1041 S. PERSHING AVENUE, STOCKT01,C1 LIC 1467293 CLISS <br />I <br />R INSURER WORLCOMP.I W.C.W. (89�� 400-96-fl7 <br />1 OHIO CASUALTY <br />C FIRR DISTRICT CITY OF MANTBCA PERMIT 1/INSPTR <br />T <br />0 LABORATORY NINBCALIFOgNIA WATER LABS PHONE 1 (209) 527-4050 <br />R <br />SAMPLING FIRM' CALIFORNIA WATER LABS SAMPLING HTNOD BRASS TUmi IBES <br />TANK 10 1 TIKK SIZE CHEMICILS STORED CURRENtLI CHEMICALS STORED PRNVIOUSL <br />1 39- ,� d 10, O�allon w diesel N A <br />----'-'�--�-4, 000 allon unleaded gasoline <br />N 39- - © 3,000 gallon su reme asoline <br />K 39- ,��� - c?3 <br />39- '7 4 000 allon re <br />39- _ <br />LIST ADDITIONAL TINK INFORHITION AS NEEDED ON SEPARATE FORN <br />illy <br />Yuamuu�uw�u�uuuDu�auswutaiu!tlatuuu�utw�uartiuutu�!w <br />P APPROVED _IPPROVRD LITH CONDITIONS DISAPPROVED <br />L (SBR I?TACHMENT WITH CONDITIONS) <br />1 PLAN RNVIEWBRS NIMR zh w, DATB�� <br />IPPLICINT MUST PERFORM ILL WORK IN ACCORDANCE WITH SIM JOIQUIN COUNTY ORDINANCES, STITR LAWS, AND RULES IND REGULATIONS <br />OF THE SAN JOAQUIN LOCAL HRILTH 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 IS TO BECOM <br />SUBJ;C? TO WORKER'S COMPRISITION LAWS OF CILIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOVING: of CERTIFY THAT IN THB PERFORMINCB OF TOR WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br />TO WORKER'S COMPENSATION LITS Of CALIFORNIA. <br />CALL FOR IN PECTIONS AT LEAST 40 HOURS IN ADVANCE <br />OFFICE USE ONLY --RN 23 016 12/11 - <br />SSSSSSSSSSSS$SSSSSSSSSSSSSSSSSSSSS SS 9SSSS$$SSSS$SSSSSSSSS$SSSSSSS$SSSSSSSSSSSS$SSS$SSSSSSSSSSSS$SSSSSSSS$$$SSS$SSSSSS <br />SWBBPS 1 COMP 1LOC CODE 0131 CODE IMOUNT DUE AMOUNT RCVD CK1/CASU KCVO 11 <br />DATR KCVO PERMIT 1 <br />