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APPLICATIO <br /> L#PERMIT SAM J6WfHI`CWA**H'('A`L`T`i' " <br /> UNDEi AIR: 1601 1 HAIELTON AVE DIST;I. <br /> CLOSURE OR ABANDONMENT Telephone (209) 468-3420 <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT III PLACE or UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY 4-, <br /> • THIS PERMIT EIFIRES 90 DAYS FROM THE APPROVAL DATE, DO HOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> ---- ----- ---- <br /> —--—---------------- <br /> EPA'SITE IROJECI CONTACT 1: TELEPHONE I <br /> 415-232-7447 <br /> rF PHONE I <br /> 415-232-7447 <br /> ;'A7 .FACILITY NAME Time Oil Company <br /> "C ADDRESS <br /> 3015 Navy Drive , Stockton , CA <br /> ,r L 'CROSS STREET Washington Street <br /> 1.1 .091DE2IOPERATOR Jeff Bailey PlIONE I 415-232-7447 <br /> P'N <br /> C CONTRACTOR NAME Western Meter Service, <br /> Inc PHONE 1 209-948-6124 <br /> CONTRACTOR ADDRESS 2735 Teepee Drive , suite EtCA LIC 1 414051 CLASS C61-d/40 <br /> YR` INSURER Golden Eagle Insurance VRK.COHPII Golden Eaql <br /> e Insuranc( <br /> 'A <br /> ------------------- 10 2 E; <br /> FIRE DISTRICT —]PER�11` LIINSPTR <br /> �T ilk 57e C ft) <br /> II11 <br /> LABORATORY NAME r <br /> ''g Emcom Associates 916-928-3300 <br /> SAMPLING FIRM' ta Soil samples will be e by <br /> sociates SAMPLING METHOD backhoe 21to4 into <br /> natio <br /> soil.' <br /> TANK IDI iii TAN 11, CHEN I CALS MORIN trTL CEN REVIOUSE. <br /> A' 39-'- <br /> 5 , 000—----------------------- <br /> -------------- <br /> K 39-- <br /> -_ --- <br /> -—---------------- <br /> ------------------ <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> 1111111111fill 112121121111111,11111 <br /> ---- APPROVED ...APPROVED WITH CONDITIONS DISAPPROVED <br /> (SEE ATTACHMENT WITH CONDITIONS <br /> PU1111101(61ERS MAHE <br /> W' r --------------------------------------------------------------DATE <br /> 'Ill=1131i 01111111; ll"t Hill man', <br /> APPI16N,plil PERFORM ALL WORK IN ACCORDANCE WITH SAM JOAOUIH COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> PERFORMANCE Or THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br /> "TO"ME <br /> EJECT -RIS COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE zii <br /> I-' I:CERTIFY THAT IN THE PERFORMANCE OF THE RORK FOR RHICH THIS PERMIT 15 ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> 010l COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 49 HOURS IN ADVANCE <br /> 4 <br /> ------ ---- - DATE <br /> - <br /> - <br /> - <br /> - <br /> - <br /> -------------------- <br /> TICE ISF oily-41 23 016 1218S -------- --------------------------- <br /> EPS t COMP DU <br /> UNIT RCYD CKI1. /CASH j R�C WDY PERMIT I <br /> vCY I LOC CODE DIST coo OU <br /> wo <br />