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I: 11"U1,AimN tux PLKMII SAN JOAOUIN LOCAL HEALTH DISTRICTt: <br />t: UNDERn" UND TANK t: 1601 E HAZELTON AVE., STOC CA t; <br />I: CLOSURD�ABANOONMENT G Telephone (209) 468-3 <br />t t� <br />IPPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br />HIS PERMIT EIPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />4�zIREMOVAL ----- TEMPORARY CLOSURE ABANDONMFNT IN aucF <br />EPA'SITE f i � <br />�7a 7 <br />�r ----- <br />PROJECT CONTACT k TELEPHONE I <br />_FACILITY HANE Brooks Products , Inc <br />PHONE 1464-7696 <br />-ADDRESS. 2441 West Charter Way, Stockton, Ca 95206 <br />'CROSS. STREET Fresno St. <br />D MWOPERATOR <br />PHONE I <br />Brooks Products, Inc (209) 464-A <br />CONTRACTOR NAME <br />Western Meter Service Inc. PHONE1 (209) 94 <br />'CONTRACTOR ADDRESS .2735 Teepee Dr. Ste. E <br />n Ca 95205 CA LIC 1 414051IIISIlAER <br />Golden Eagle Ins. WORK.Fremon <br />FIRE:DISTRICT Bogg's Track PERMIT I/INSPTR <br />-,<'""' """ Canonie <br />Engineering <br />`S1MPC3)IG' FIRMI <br />TANK ID I <br />NAME <br />IPHONE I (209) 983-1340 <br />SAMPLING METHOD soil will be excavat <br />backhoe -samples will <br />TANK SIZE (CHEMICALS STWD �i1�AR�Y��IFTLMS �VFPREVIOUSI <br />2000.ga1. gas <br />LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br />APPROVED APPROVED WITH CONDITIONS ___ DISAPPROVED <br />(SE,41`TACANT WITH CONDITIONS) <br />PUT PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br />"DADUIN LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br />ERFORNANCE Or THE WORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL NOT EMPLOY ANY PERSON 1N SUCH MANNER AS TO BECON <br />TO`WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />St+ I?CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL EMPLOY PERSONS SUBIEC' <br />PS )COMPENSATION LAWS OF CALIFORNIA. <br />_L. FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br />--- ----- --------- D - <br />f:DYU.rEB 2 0l8 !1/88 - - - - - - - ATE --- ---- <br />ffffffiffif ffffffffffffftfffffffffffffftfffffffffftffffffftffffffffffffffffffffffiffffffffffffffffffffffffffff� <br />COMP- )LOC CODE IDTST CODE) AMOUNT DUE I AMOUNT RCVD I CKf/CASH I RCVD BY DAJE RCVD I PERMIT f <br />�7U of _. 3'Lt C,n� or„� ,i„_.� - <br />