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Q:ft R R:ft ft.ky R.,R:ff R ft ti: <br /> APPLICATION FOR PERM, SAN N LOCAL HEALTH DISTRICTI: <br /> UNDERGROUND TANK 1601 1ELTON AVE., STOCKTON CA t; <br /> U <br /> CLOSURE OR ABANDONMENT t: Telephone (209) 468-3420 t: <br /> tf I:r... tt.tt-li <br /> .......... <br /> j AA h PCZ I ,:� <br /> 1,11 z-J <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STrRAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT--TYPE,'-fiELflV&L HE;yLfll-i <br /> PERM14 i ISLRViCES <br /> REMOVAL ..... TEMPORARY CLOSURE .... ABANDONMENT IN PLACE <br /> EPA SITE I PROJECT <br /> CAC 000142845 PT CONTACT I TELEPHONE I E3111 R-echt),�old <br /> . � <br /> F FACILITY NAME <br /> Frank 1 s Exxon #2 =PHONE # (200 ) 835-2750 <br /> C ADDRESS <br /> I --- 1 399 East Yosemite Avenue , Yanteca , CA <br /> L CROSS STREET <br /> I <br /> I -Northwoods <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> Jerry Moore/Frank Guinta (2C9 ) 83-P- D750 <br /> C CONTRACTOR NAME <br /> B & C Construction Comrany PHONE 1 (209 ) Or-1-0-�C)k <br /> 0 <br /> N CONTRACTOR ADDRESS r-,637 North Ferah ing ,—A--3— CA LIC 1 4 CLAS <br /> tockton CA 952C7 971 A <br /> Stockton 1 <br /> R INSURERWORK.COMP1 <br /> A i e . Cn File <br /> C FIRE DISTRICT PERMIT #/INSPTR .. <br /> ---Manteca City <br /> 0 LABORATORY NAME <br /> R Canonle PHONE # (209 ) 983-1340 <br /> SAMPLING FIRM# anonie SAMPLING METHOD Drive IIethcrl <br /> TANK ID I TANK SIZE CHEMICALS STORED CURRENTL <br /> T CHEMICALS STORED PREVIOUSL) <br /> A 39-.3.Q Waste t e waste Cil <br /> gA--------- 1 QQQ- Gallons oil <br /> K 39 <br /> 39-------------------------- <br /> 39---------------------------- <br /> LIST <br /> 9- -----------------------39-- ------------------ <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P PROV <br /> L ---APPROVED WITH CONDITIONS .... DISAPPROVED 1 <br /> A PLAN REVIEWERS NW ED (SEE ATTACHMEr wp CON TIONS) <br /> N -- ----------DATE--- <br /> APPLICANT MUST PERFORM ALL WORK IN-WCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANI� REGULATIONS <br /> Of THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I' CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOW116t 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECI <br /> TO WORKER'S COMPENSATION LAWS Of CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED �..- <br /> =- �-------------------------------------------DATE 1-12-89 <br /> OFFIC5SE ONLY—Ex ?1 #16 121jj ----------------------------- <br /> sssssstssssssssftsssssstssssssssssssssssscsssssssssssscsssscsssssssssssssscsssssscsssssssccccscscsccscsscsscccsssccccccss <br /> SWEEPS I COMP I LOC CODE IDIST CODE J AMOUNT DUE I <br /> ilu A 1UNT RCVD CKI/CASH RCY <br /> 0 By ATE RCVD P=ER1I.T=j <br />