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*; APPU CA11UN tUR PERMIT *: SAN JOAQUIN LOCAL HEALTH DISTRICT*; q <br />*: UNDER' .,ND TANK *: 1601 E HAZELTON AVE., STO CA*: <br />CLOS UkEVABANDONMENT *: Telephone (209) 468-3 <br />;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 IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_ REMOVAL ----- TEMPORARY CLOSURE ABANDONMENT IN PLACE <br />EPA�SITE # f PROJECT CONTACT f TELEPHONE #I <br />CAC 000543856 <br />FACILITY NAME Precissi Flying Service PHONE # (209) 369-4408 <br />"ADDRESS 11919 N. Lower Sacramento Road, Lodi, Ca 95242 <br />"ADDRESS <br />"CROSS .STREET <br />r...,•�'d.�., & Lower Sacramento Road <br />__[OPERATOR <br />aR John Precissi PHONE # <br />Peter Precissi (209) 369-4408 <br />J[g_�TRACTORNAME <br />" Western Meter Service, <br />Inc. HONE # <br />(209) 948-6124 <br />CONTRACTOR'ADDRESS 2735 Teepee Drive, <br />SuiteA LIC # <br />IE <br />414051 CLASS <br />C61/D-40 <br />!Imam <br />Golden Ea le Insurance <br />ORK.COMP.# NWC110296 <br />, FIRE -DISTRICT <br />San Joaquin County <br />PERMIT#/INSPTR <br />L� <br />t � �� 4( � <br />TORY WE `� Y <br />; <br />PHONE # <br />(2 0 9)46'- <br />Ike FIRM <br />.� ,... TS Environmental <br />SAMPLING METHOD <br />Soil excavation <br />by back <br />TANK ID I i <br />�,... <br />TANK SIZE CHEMICAL�TOWO=CUkakT CHEMICALS STORED PREVIOUSI <br />10,000 gallon aviation fuel same <br />.r. »---------------- <br />�y"LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br />APPROVED __-APPROVED WITH CONDITIONS ___ DISAPPROVED <br />(SEEEVIEM NAME 11 ATTACHMENT WITH CONDITIONS) <br />-- ---- -------------------------------------DATE----- ----------__. <br />`PERFORM ALL WORK IN_AkCtORDAHCE_WITH.--SAN--JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br />riSm"JOAMIN10CAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br />'P£RFORItA?JCE OF1 HE RORK-FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO-BECOMI <br />JO�YORICER'S'COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />.Y IN6101':CUTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br />�I. 'S COlIPENSATION LAWS OF CALIFORNIA. <br />rb-CALL..-F-OR IN PE ONS AT LEAST 48 HOURS IN ADVANCE <br />r: <br />----- --- ---------------- g DATE 12 - 2 0 - 9 0 <br />FICE 9SE:OitY--fB 13 Dob 11 8 Burl DuBose, General Mana er---r---- --------"---'-----"-- <br />ifffffffffifffffffffffSfSfffSfffSfffffffffffffffffffffffffffffESiffffffffffffffffffffffSfffffffifSffSffffffffiffffffff <br />PS #r COMP'# LOC CODE GIST CODE AMOUNT DUE I AMOUNT*CVD I CK#/CASH *CVD 8Y DATE RCVD PERMIT # <br />IN <br />