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unuenutwunu oni% &uyx a nnLCLIUM ML., 4tuf.nlur gent 3.{ <br /> �r � t CLOSUREOIIABANDONMEAI r: Telephone (209) 468-?"S t ' <br /> s APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY- <br /> „:`THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE 1N ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br /> X_ REMOVAL TEMPORARY CLOSURE _ ABANDONMENT IN PLACE M1 <br /> EPA'SITE #. PROJECT CONTACT & TELEPHONE I Western _Meter Ser- s <br /> vice Inc. <br /> F ;FACILITY NAME PHONE I '( <br /> St. Jose hs-.HoSeital— 209 948-6124 {yK <br /> 41111RESS `r-- <br /> + � 1800 North California Street Stockton, CA <br /> his 'C�os°s'�STREET <br /> 5.aHardin ` '..: <br /> T¢ ;OIt/OPERATOR- -.. <br /> a, ,.,: PHONE I : . <br /> Roek Brothers Construction _ (_209) 464-8344 <br /> M C CONTRACTOR NAMEPHONdt <br /> E I T� - <br /> O� Westerh Meter Service Inc. 209 948-6124 <br /> ''CDNTRACTOR•ADDRESS 2735 Teepee Drive, Ste. E CA LIC I <br /> CLAS,, <br /> TY S ockton CA 95205 414051 C-61-040 <br /> e, <br /> INSURER ' <br /> p _ - YORK:COMP.# r-) <br /> Vit* i <br /> NWC49255 <br /> `CS 3 FIRE DISTRICT - PERMIT #/INSPTR " <br /> : Z * . <br /> 'f s 30 LABORATORY NAME PHONE t• <br /> R' "' 209 983-1340 <br /> 7k <br /> $� ' , SAMPLIH6 FIRMS SAMPLING METHOD Soil sample to be taken <br /> from backlinin 1-1-1-t- 9-4 f <br /> 14` TANK f0 # TANK SIZE CHEMICALS STORED CURREHTLI CHEMICALS STORED PREVIOUSL nat I-�: <br /> �. . •T soil �. <br /> f . <br /> A 39- p -of Diesel <br /> ;�3_ __ ---- r..: <br /> ------------------- <br /> --------------- <br /> --------------- <br /> --------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM y " <br /> ��� ��"� Ititl((�II � lea� • <br /> r�^-tidy, t �•. f s s�•-. . <br /> APPROVED _APPROVED WITH CONDITIONS DISAPPROVED <br /> E ____ <br /> E <br /> AT HMENT WITH CONDITIONS) <br /> �*A PIAN REVIEWERS NAME °�! �,--- ------ -- - --------------------------DATE-----� -- - - .: .^' <br /> / i• p <br /> wVq <br /> y; <br /> APPLICANT;:MUST'PERfORM ALL YORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE-LAWS, AND RULES AND REGULATIONS:. <br /> �'FO T}E°SAIf10AAUIN•LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWIN6: ' <br /> :•,Tv;:...;,�•.. .:.,... , I CERTIFY THAT �`,:: <br /> =1N.;TIIE;PERFDRMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO'8EC0 v" <br /> JECT-JO`WOBKER!S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES IHE <br /> , ONIN6r'I'CERTIFY THAT IN THE PERFORMANCE OF THE NORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJ€C <br /> $r ' 'COMPENSATION LAYS OF CA <br /> ?O�WORKER S' LIfORH•IA. <br /> c CALLVFOR INSIS CTIONS AT LEAST 48 HOURS IN ADVANCE <br /> --------------------- Wes Dubose DATE 12/2! <br /> fF16E1SCONLY--11 13 046 11/88 -- ------------------- ------------------------- YV <br /> .� ifffffffffffffifffffffffSffffffifffffSffffSffffffffffifffffffffffSfffffffiSfiffiffftffifffffifffiffffffffffffffffiffffff ='' ���r�f <br /> SWEEPS±t> :COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CKI/CASHRCVD BY i DATE RCVD PERMIT # <br /> Y:w� <br />