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CIO <br />F k:r kfi.tfi. a R. kt. IT. k1:r- tv. tv. tv. kfi.Fr. t:�tfi.*tfi.tfi.Ffi.kfi.kfi.tvtfi.ti.t • ifi-Mkfi.k1f <br />IPPLICATION FOR PERMIT w SAN JOAQUIN LOCAL HEALTH DISTRICT:: <br />t: UNDERGROUND TANK t: 1601 B HIZELTON AVE., STOCKT01 CAT: <br />t: CLOSURE OR 1111DONMENT t: Telephone (109) 468-3410 t: <br />t. kfi.11: ki: it: kfi. tfi-tfi: kfi. kfi" M: kfi. V . kfi. A: kfi- tfi-l'fi. kfi. tfi. R. kfi- tfi. tfi-tfi. kfi. kfi., kfi., R; 3: tfi. M. 0: <br />IPPLICITION FOR PERMANENT/TBMPORIRY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br />THIS PERMIT EXPIRES 90 DIYS FROM THE APPROVIL DITE. DO NOT 11179 IN 111 SHADED AREAS. INDICATE PERMIT TYPE 1ELOW: <br />X REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLICB <br />BPA SITE 1 PROJECT CONTACT i TELEPHONE 1 <br />CAC 000 520 992 kql - <br />F FACILITY NAME Pacific Bell PHONE 1 <br />A ___. <br />C ADDRESS 124 West Elm Street <br />1 <br />L CROSS STREET North Church Street <br />I <br />T OWNER/OPERATOR PHONE 1 <br />Y Pacific Bell/Steve Wat (916) 972-2417 <br />C CONTRACTOR NAME ivUd.e.. 0 lldrf'-C'a-farf -�� PHONE 1���- mm5���•^��a�'��---.- <br />0 American Environmental Mana ement Cor (916) 364-8872 <br />N CONTRACTOR ADDRESS 9719 Lincoln Village Drive #501 CA LIC 1 CLASS <br />T___ Sacramento, California 95827 464_159_ A-HAZ <br />R INSURER Marsh & McLennan, Inc. 1ORK.COMP.1 CJ9069663 <br />C FIRE DISTRICT City of Lodi PERMIT 1/INSPTR TBA/Steven W. Raddi an <br />T Fire Department <br />0 LABORATORY NAME PHONE 1 <br />R American Environmental LaboratoryCor (916) 638-7301 <br />SAMPLING FIRMt American Environmental SIMPLING METIOD Hand Sampling with <br />t Corp 6" Brass Tubes <br />TANK ID 1 TANK SIZE CHEMICALS STORED CURREITLI CHEMICALS STORED PREVIOUSL <br />T <br />1 39- i Co _QZ �- 550 gallon none Diesel <br />1 39_ (Q - 2000 gallon Diesel Diesel <br />K 39- <br />39- <br />39- <br />LIST ADDITIONAL TINK INFORMATION AS NEEDED ON SEPARITE FORM <br />IINHNHHHNII'tlllYpNIHNWtlYIHIIUH�IHIWHHINNNtlIUfHYIUIIIIN ' IINHHIIIHNI�IIItIIIIIHINHIIIIHIIHINIIIHtHi!IHNiHUHIHHtlIINIHNtlUG'IHHNHItl01UiHINHHIt'JIItlP�tlNl�gliHHIiHINHIHHIHHtlIUHHIItlIWIHHHIHIHNfIIHIHHHHItlUHHIINIRIIIMI HIHNIIIIHIN' <br />P APPROVED _ IPPROVED WITH CONDITIONS _ DISAPPROVED <br />L (SEE ATTACHMENT WITH CONDITIONS) <br />A PLAN REVIEWERS MAKE <br />APPLICANT MUST PERFORM ILL WORK II ACCORDINCE WITH SAN JOAQUIN COUNTY ORDINANCES, STITE LIWS, AND RULES AND REGULITIONS <br />OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNITURE CERTIFIES THE FOLLOWING: 'I CERTIFY THIT <br />IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY IVY PERSON IN SUCH MANNER AS TO BECOM <br />SUBJECT TO YORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNITURE CERTIFIES THE <br />FOLLOWING: 'I CERTIFY THAT IV THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHILL EMPLOY PERSONS SUBJBC <br />TO WORKER'S COMPENS/TION LAWS OF CALIFORNII. <br />CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br />SIGNED_ ____6�Q ?�--- q� <br />OFFICE US ONLY --EH 23 046 12/01 r <br />$SSSS$SSS$SSSSSSSSSSSSSSSSSSSSSSSSSSS$SS$SSS$SSSSSSSS$SSS$S$$$SSSSSSSSS$SSSSS$$SSSSSSSSSSSSS$SSSSSSSSSSSSSSSSSSSSSS$S$SS$ <br />SWEEPS I�IMCORP 1 I.LOC CODE DIST CODE AMOUNT DUB AMOUNT RCVD CKI/CASH I RCPD BY I <br />O1tE RCVD I PERMIT 1 <br />3S <br />