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M <br />F kv ki: ff 1: ff ki: ktit; Vt. tv. ti., tv tv. ft. tv tt. ft* tV tt-R:R:a ft 3: 1: ft ti: 3: <br />1PPLICI'fIOY FOR PERMIT w SIY JOIQUIM LOCAL 18101 '6IStRICtk: <br />t: 910IRCROUND TANK t: 1101 E HAZBLtOM AVE., SIOCKT01 Clt: <br />k: CLOSURE OR IIINDONNB11 teleplooe 12011 111-1120 k: <br />APPLICATION FOR PIRMINKII/TBMPORIRY CLOSURE OR 161100KNENT IM PLACE OF UNDERGROUND HAZARDOUS SUBSTIICBS StORIGE FICILITY <br />THIS PERMIT EXPIRES 10 DAYS FROM ?HR APPROVAL DATE. DO NOT 11171 IN All S111011 AREAS. INDICITE PERMIT TYPE 11LOV: <br />_X._ 11MOVAL _____ TEMPORARY CLOSURE I81100NMBMt 1N PLICA <br />BPA Sltl 1 C /- -). ��/ ^ I PROJRCT CONTACT I TBLEPMOMB 1 <br />OV v <br />5 <br />P PICILITY MINI <br />Knox' s Texaco <br />Food Mart <br />PHONE <br />1 <br />209-754-1808 <br />PO Box 950 <br />M CONTRACTOR ADDRESS <br />CI LIC 1 <br />A-Haz, <br />CLASS <br />C ADDRESS <br />1 <br />633 E. Victor <br />Road, Lodi, CA 95240 <br />L CROSS StIIII <br />Cherokee <br />I <br />1 INSURRR tate <br />Com ensation Insurance <br />Fund VORK.COMP.1 265057 <br />C FIRt DISTRICT <br />City o f Lodi <br />PERMIT 1/I1SPTR <br />I OVNER/OPRRITOR <br />Chris Knox & <br />Dave Knox <br />PHONE 1 <br />Y 4571 No. <br />Pershing Ave, <br />Stockton,CA 95207 <br />0 LI80RAtORY MIME Geoanalytical <br />TH A. TALLIA <br />-Asa-lRnR <br />New (none) <br />209-478-0365 <br />C COIITIICTOR MIME <br />PMOMB I <br />0 <br />OIL EQUIPMENT SERVICE <br />209-754-1808 <br />PO Box 950 <br />M CONTRACTOR ADDRESS <br />CI LIC 1 <br />A-Haz, <br />CLASS <br />S a n Andreas , C A 95249 <br />3234 17 <br />C 61 D 4 C <br />1 INSURRR tate <br />Com ensation Insurance <br />Fund VORK.COMP.1 265057 <br />C FIRt DISTRICT <br />City o f Lodi <br />PERMIT 1/I1SPTR <br />I <br />0 LI80RAtORY MIME Geoanalytical <br />Labs Inc. <br />PMOMI 1 209-572-0900 <br />R <br />SINPLIHC FIRM' <br />TINS !0 1 <br />P <br />L <br />/ PLAN RIVIEVBRS MINI <br />M <br />r E_a_rth Tech. Inc. SIMPLIMG METHOD Per LUFT manual <br />till SIZE ICHBMICILS $$TORSO CURREAM CNMICILS 310110 PRBVI <br />LIST ADDITIONAL 110K INFORMATION AS NEEDED Of SEPARATE FORM <br />It -PROVED _APPROVED VIIH CONDITIONS DISAPPROVED <br />/7 jS66 ITTICHNEYT 9111 CONDITIONS) ~ <br />, MR /1 -9 - <br />APPLICANT MUST PERFORM ILL VORK 11 ICCOROINCE WITH SIM JOAQUIN COUNTY ORDINANCES, STATE LIVS, AND RULES AND REGULATIONS <br />OF TNR SIN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGINT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY TRIC <br />IN ?H1 PERFORMANCE OP THB WORK FOR VNICN THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IM SUCH MINMER IS TO RICOH <br />SUBJECT t0 WORKER'S COMPEMSITION LIVS OF CILIP0RNI1.' CONTRICIOR'S HIRING OR SUBCONTRACTING SIGNITURE CERTIFIES THE <br />FOLLOVING: 11 CERTIFY tHlt IM tM6 PERFORMANCE OF 111E VORK FOR WHICH THIS P11MIt IS ISSUED, I SHALL EMPLOY PERSONS SU8JRC' <br />TO 1014114 COMPENSATION LIVS OF CALIFORNIA. <br />CFO," NSP P. Y ONgf5lGT' LEAST 4 4 H0Ut2S I N ADVANCE <br />4-2-91 <br />OFFICI'USI ONLY—IM 23 04'12111 `KEITH A. TALLIA, President Oil Equipment Service <br />SSS9SISSSSSS"rSSSSSSSiSSSiSSSSSSSiSSSSS�S9SSSiSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSi9SiSSSrSSSSSSSSSSiSSiiSSSSSiSSSSSSSiS1SSS <br />SVBBPS I CORP I LOC CODE OISt C00 AMOUNT DUl AMOUNT RCVD I CK1/CISH I RCID RY I Dill RCVD I PERMIT <br />