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k�kfi�C#�tfi�k�fi'kfi�kfi�kti�kfifi�kfi�Cfi�Cfi%C�Cfi�kfi�kfi�kfi�kfi�4fi�kfi�kfi�l'fi�kfi�kfi�kfi�k�fi�kfi�kfi�kfi� <br /> APPLICATION FOR PERMIT SIM JOIQUIN LOCAL HEALTH DISTRICTk: <br /> k: UNDERGROUND TANK k: 1601 E HAIELTON AFB., STOCKTON Cit: <br /> k: CLOSURE OR ISAMDONKEIT k; Telephone (2091 468-3420 k: <br /> k kt V@ 41:R:Cfi:kfilIt tYIII:R It:ft.R:tV R:R:ff.R R:kfi'k-C:ffffR:k1:R:ffR:R:R:0: <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HIZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EKPIRES 90 DIYS FROM THE APPROVAL DATE. DO NOT FRIT8 IN AIT SHADED AREAS, INDICATE PERMIT TYPE AELOY: <br /> - REMOVAL -__ TEMPORARY CLOSURE ABINDONMENT IN PLACE <br /> EPA SIfE�I w��--�—�- PROJECT CONTACT i TELEPHONE I -�- <br /> _�..__ <br /> CAC000159045 <br /> F FACILITY MAKE PHONE I <br /> A Saharqun Plumbing <br /> C ADDRESS 2216 Stewart St . <br /> L CROSS STREIIT <br /> I --San2uinetti Ln. <br /> IOWNER/OPERITORTom Sahargun PHONE <br />� C CONTRACTOR MIME PHONE I <br /> 0 PCI Environmental Eng. 927-8155 <br /> N CONTRICTOR ADDRESS CI LIC I CLASS <br /> I ._._.____.-._--___.- 2076 Ac o ma St . � A <br /> - 533721_ ______ <br /> R INSURER State Fund Insurance of Calif. WORK.COKP.I 1056580 <br /> C FIRS DISTRICT PERMIT IIINSPTR <br /> City of Stockton - I^ Letitia Resch <br /> 0 LABORATORY NINE-eani Lab. PHONE I <br /> R <br /> SAMPLING FIRM* PCI Environmental Eng. SAMPLING KETKOD Each en? yiec - br: <br /> - WRk�WWWUIW�WIIIIWR!WIIINIIIIIdIWIIpINNWCWINII)NIDIiIWiIWI�gIWI --•--- _ _. ;�?T'Y _ g, r _ ___..--.-_ <br /> TANK 10 1 TANK SIZE CIIEKICILS STORED CURRgNT6 ;CHEKICALS'STORED PRBVIOUSL <br /> T <br /> -2Gasoline-� --- <br /> K 39- <br /> LIST ADDITIONAL TANK INFORMATION AS HEEDED ON SEPARATE FORK <br /> I U111IN WIIIII!illllll}ikl!fIIN!1!lullll!lli!4GHN!II!IpiiWRlkIIfICIkJ!IW!!IliII I!lAtli!I!filIICJII'J!!li!laillu lul�l'Ji!BIIWIIIIk1WIlaW4uWlllICG14!llpllll!ill�li llli!kUG'IlWIItl IICWIiINiJNIiUf!!dlull�l!!II!WI�" <br /> P _ PPROVED __APPROVED WITH CONDITIORS - DISAPPROVED <br /> L 17 (SEE ITTICHMENT W1?H CONDITIOWS)- I <br /> I PLAN REVIEWERS NINE --r� _�P ,�---DAfE q <br /> N --j1- *7 <br /> 0L_.._I✓rWWJW�WIRD�iIWdl!RY!WID!YRDIDW <br /> APPLICANT MUST PERFORM ILL WORK 11 ACCORDANCE WITH SIN JOIQUIN COUNTY ORDINANCES, STITE LIES, AND RULES IND REGULITIOHS <br /> OF THE SIN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN TNR PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br /> SUBJECT f0 YORKER'S COMPENSATION LAYS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATIOM LAYS OF CALIFORNIA, <br /> CALL FOR INSPECTIONS .AT LEAST 48 110URS IN ,ADVANCE <br /> SIGNED _ DATE <br /> OFFICE USE ONLY--BH 23 046 12/11 <br /> SSSS$$SSSSSSSSSSSSSSSSSSSSSSSSSSSS$SSSSSSSSSSSS$SSSSSS$SSSSSSSSSSSSSSSSSSSSS$$$SSSSS$$SS$SSSSSSSSSSSSS$SSSSSSSSSSS$SS$SSS _ <br /> SWEEPS 4 I COMP I I LOC CODE JOIST CODE' AMOUNT DURI AMOUNT RCVD CKI/CASII RCVD BY I DITE RCVD PERMIT I <br />