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*01 <br /> APPLICAPERMIT r SAN JOAQUIN LOCAL HEALTH ICTt: <br /> t: UNDERGROUND ?Awl t 1601 B HIZELTON IVB., STOCKTON Clt: <br /> t: CLOSURE OR 111NDONMENT t Telephone (209) 169-3110 t: <br /> t:kt:91.it:tt ti:Lt:ti:tt Lt ttt Lt ft Lt Lt ti:Lt Lt t t:Lt tt Lt R.R:R:tt tt Lt R:tt Lt tt R: <br /> 1PPLICITION FOR PERMANENT/TBMPORIRY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTINCES STORAGE FACILITY <br /> THIS PERMIT BZPIRBS 90 DIPS FROM THE APPROVAL DATE. DO NOT WRITE IN III SIIADRO AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE 1BINDOMMENT IN PLACE <br /> EPA SITE I C C O Q Q A �c� ]oZ I PROJECT CONTICT i TELEPHONE I <br /> _...._.___.__ � Larry Moorman...— _ <br /> F FACILITY NAME Moorman's Water Systems PHOME 1 (209) 931 -3210 <br /> C ADDRESS 2120 Wilcox Rd. Stockton, CA. 95205 <br /> L CROSS STR11T Waterloo Road <br /> ? OWNER/OPERATOR PHONE I <br /> Y Larry Moorman same <br /> C CONTRACTOR NAM[ PHONE <br /> 0 Moorman' s Water Systems same <br /> N CONTRACTOR IDDRBSS CA LIC I CLASS <br /> 1 - - 2120 Wilcox Rd. 468816 —� � C 61 -- <br /> R INSURER WO1K.COHP.1 <br /> j ]t v Insurance .._.--- State Fund <br /> C FIRE DISTRICT Waterloo-Morada PERMIT I/INSPTR <br /> 0 LABORATORY NIMB PHONE I <br /> R F.G.L. Labs - 942-0180 <br /> SAMPLING FIRM' F. G. L. LABS SAMPLING METHOD <br /> Nam <br /> ?INK ID I ?INK S12E CHEMICILS .STORED CURRENTLY CHEMICILS STORED PRE'JIOUSL <br /> _Reg. _2.: <br /> N 39- <br /> K 3 9-_ <br /> 39-_ - <br /> - �— - LIST ADDITIONAL ?INK IHFORHITION AS NEEDED ON SEPARATE PORN <br /> uuuluulRW!WWWIUWUW mrw!uwwuuww!w!ulc�w!!u!w!uuu�u�uu!iuuu�uuwuuuw!uwuu�'luu!uuuuuura!uauuu!ul!i�ucuuw�uuuu!uuuwuwuuwuuw!uuuul�uwu;!wuu!w�aluwuuuu�u!uu!s!auuuul <br /> P APPROVED IPPROVED WITH CONDITIONS _— DISAPPROVED <br /> L EB ITTACHHE Y WITH C04DITIONS) <br /> I PLAN REVIEWERS NAME <br /> N <br /> WAW;WWUtuIIWikIIRWYiIYWWWGYWtlW,gIINiWIUIIi iW l L4 fl;dL,iYWW <br /> IPPLICANT MUST PERFORM ILL WORK 10 ICCORDINCE WITH SIN JOIQUIN COUNTY ORDININCES, STITB LIPS, IND RULES IND REGULITIONS <br /> OF TNS SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNITURS CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH ?HIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MINNER AS TO BECON" <br /> SUBJECT TO WORKER'S COMPENSATION LAYS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY ?HIT IN TIIB PERFORMANCE OF TIIB WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUOJEC <br /> TO WORKER'S COMPENSATION LAWS OF CILIFORNII. <br /> CALL COR INSPECTIONS AT LEAST 40 110URS IN ADVANCE <br /> SIGNED__— ,��� °��?2i-,-. - —_DATE— 5—��--�� ---- <br /> OFFICE USBi LY--EN 23 016 12/81 ' — <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SWEEPS I COMP OC CODE DIST CODEi AMOUNT DU8AMOUNT RCVD cK1/C1sH RCYD BY DITB RCVO PERMIT <br />