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t: 1,LUWKlt UK AUANUUNRtNI Telephone (209) 468-3420 -N <br /> tal.......... <br /> APPLICATION TOR PERMANENT/TEMPORARY PURE OR ABANDONMENT' I`N­PLACE"0`F'*U`N`D`E`R'BR`O'U"N'D'1RRDOUS SUBSTANCES STORAGE FACILITY <br /> -THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE. BELOW: <br /> V4- <br /> _aEMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> P, EPA SITE I CArOC)C>2 - WES <br /> 3.qzl PROJECT CONTACT TELEPHONE 1. TERN METER SERVI <br /> 209 )94 <br /> 8-6124 <br /> F, FACILITY NAME <br /> PHONE I <br /> MRS. MASUDA <br /> (209 ) 982-0296 <br /> C, 'ADDRESS <br /> 288 -EAST -6TH STREET, FRENCH CAMP, CALIFORNIA <br /> L CROSS STREET <br /> ".t <br /> J, AOWNER/OPERATORPHONE I i <br /> MRS. MASUDA 209) 982-0296 <br /> 'CONTRACTOR NAME A <br /> PHONE I <br /> WESTERN METER SERVICE (209) 948-6124 <br /> 4' "CONTRACTUR ADDRESS 2735 TEEPEE DR. STE. E <br /> CA LIC I CLASS <br /> 'T, <br /> -S—TOCKTO-Ni CALIFORNIA 95205 414051 C/627D/40 <br /> A, <br /> GOLDEN EAGLE INSURANCE CO. <br /> 0 49255 <br /> 1R :INSURER ORK.CONP.1 <br /> CFIRE DISTRICT IRE DISTRic ERMIT I/INSPTR <br /> 4,11" ��LAMTUY WE <br /> PHONE t. <br /> I C ( 209 ) 983-1340 <br /> G FIRM* <br /> ONIE ENGINEERING SAMPLING METHOD USING BRASS TUBE OUT OF <br /> TANK ID I TANK SIZE CHEMICALS <br /> RIII liTL HENCALS STORED PREVIOUI <br /> 39� <br /> --—------—--------------- <br /> --—--—------------------- <br /> ---------------- <br /> 9�-,,.77----—---------------- <br /> --------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> APPROVED APPROVED WITH CONDITIONS <br /> --- DISAPPROVED <br /> 4 <br /> EE CIMENT WITH CONDITIONS) <br /> REVIEWERS NAME <br /> ------- ----------- <br /> - - ---------------------------------- DATE <br /> I�L7 <br /> .......... <br /> law" <br /> �DIAPPLIGWTR,fMRIST'PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> F'�ITMWWkllll LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> _I., <br /> fm1;wF4MN' CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br /> I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO'BECO <br /> CT,,,',TD- <br /> COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE <br /> JaWING:>>'Y CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I <br /> SHALL EMPLOY PERSONS SUSJEC <br /> ATO YORKERS COMPENSATION LAWS OF CALIFORNIA, <br /> 4CAL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> C MSVOILYI 23 4 12188 -------------- <br /> E, <br /> I ILOC CODE JOIST CODE AMOUNT OUE AMOUNT RCV0 CK11CASH RCVD By DA <br /> PERMIT E CVO 1] <br />