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t k;:kt:t14✓ '�t�:t;t;tx�t;:t�:C�:tz t;:t�l4:tt t;t t�:tt:IR:t;t:►,r,,,,`1 k;:t;: V. <br /> APPLIC'i,41 POR PERMIT w SIN JOIOUIY LOCAL BEILti. ,iSTRICTt: <br /> t: VIDERGROUND TAM[ t; 1601 B HIZILTON Ill., STOCKTON Clt: <br /> t CLOSURE OR 111NDOMMENT t: Telephone (209) 166-3120 t; V <br /> k:R:R:t2!R:R:ti:t;.R:k3:RVR:R!R:ki:R:R:k3:ki:Rt3:t;:R:k3:R:R:k3:R:R:R:k2:ki:it: <br /> APPLICATION FOR PERMANENT/TEMPORART CLOSURE OR ISAIDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT IIITB IN 11T SIRDID AREAS. INDICATE PERMIT TYPE IBLOW: <br /> - - REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE I CAC00196613 TP�JHC—Tcof?ICT i TELEPHONE I Erik Friedrich (Weston) <br /> F FACILITY MANE NONE PHONE 1 209-476-1;63,5, <br /> C ADDRESS 48 N. Wilson Way, Stockton, Ca. <br /> I <br /> L CROSS STREIT Weber <br /> I <br /> ? OWMER/OPERITOR Raymond Rishwain D.D.S . PHONE I 209-466-0478-.' ' <br /> T <br /> C CONTRICTOR MIME Decon Environmental Services PHONE 1 415-732-6444 <br /> 0 <br /> Y COYTRICTOR IDDRBSS 26102 Eden Landing Road, #4 CA LIC 1 545726 <br /> CLASS p� <br /> T — 94545 -- <br /> R INSURBRPlanet- Gen. Liab. & Pollution Liah gORK.COMP.1 025811975 <br /> A ___ i rrn�- wnrJ �! r-mmP_-- _— — --- - <br /> C PIRB DISTRICT � �` � PERMIT 1/INSPTR . <br /> 0 LABORATORY NAME `T- C+- a PHONE I <br /> Roy F. Weston, Inc. 209-476-1635 <br /> R <br /> SAMPLING FIRMt Roy F. Weston, Inc. SAMPLING METROD8015 ,w- 46 . d, 8020 <br /> W�"�uuluu;u�>r�r�uulu�uptilNr�uum�tun�tl�i�;i�l!d�nl� -- DOHS x <br /> ?INK ID I TIKK SITE CHEMICALS STORED CURRENTLY CHEMICALS STORED PRBVIOUSL <br /> 1 last known- <br /> lesA L39--a.-3 C- O/ s than 1009 c rhe- empty`_ gaso tile <br /> Y 39- _ _ - <br /> [ 39- — <br /> 39- <br /> -- LIST ADDITIONAL TANK INFORMATION IS NEEDED 01 SEPARATE FORM <br /> IIIIUtG'WUUtltWI�UIiUIIIUIUUNIDIWUItl11UIlUUUUIUiUfUWUU1WiUY1pl! TUU' NUUIIiq;OWliIIIIIIIIIIIIUJr�G!itll�lClL^iii!YU ""IUUIL'UIIJIL'9wUE!71di!11;:IU11;1GiU9U]�iwl�.dlU:'ul?IJi.�UIUUIgpy!I;;;L'riIW19L'1JUUUIIUIIU'ullUltlli!L'iIbW1HUT;TIL'WC"JIJIUI7l!Lh1101i"IIItlUE ;� <br /> P _ _ APPROVED _ IPPROVBD WITH CONDITIONS _— DISAPPROVED Ik <br /> L i SEB ITTICUMEN? WITH CONDITIONS; <br /> I PLAN RBVIEWBRS NAME _ Lam'^�� - - -- u1TE_�_ 6 l <br /> 'Zd?� ;u <br /> UII�WlIU1aYY[NIUlIHYi�igIWWIU�tYU� <br /> YI6�UllRUNIUi�iiCkNUiItUUUUUWRItliIUUtWUUBUIUUL'UtW16UUIL'UDUUtlUIYIfUtlIUfUUWiR�RYI�YYlU4N19Yfi�fi�P <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SIN JOAQUIN COUNTY ORDIVINCES, STI?E LAWS, AND RULES IND 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 MINhER IS TO BECOM <br /> SUBJECT TO WORKER'S COMPENSATION LIWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 11 CERTIFY ?HIT IN THE PERFORMINCB OF 7116 WOR[ FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LITS OF CALIFORNIA. <br /> CALL FOR INSPE TIONS j,T LEAST 40 HOURS IN ADVANCE <br /> SIGNED — _-- y-- ^DATE_ <br /> OFFICE USB ON' -BTI 23 04'12/if <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS�-S`3SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS <br /> SIBEPS 1 COMP ILOC CODE] DIST CODE' AMOUNT DUE AMOUNT RCVD ASII RCVD BY 0171 RCVD PERMIT I <br /> 9"0048 a�� L_._.0-_. ..__3a3..._�..._7y6_._ �y6 I �y-7___._.I_.wRs 1._�I3�8� <br />