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STATE OF CALIFORNIA• DEPARTMENT OF TRANSPORTATION ENCROACHMENT PERMIT TR-4120(REV.2198) Permit No. 1004-6SV-0479 Dist/Co/RtelPM In compliance with (Check one): 10-SJ-33-0.16 ® Your application of RUNE 16, 2004 Date ❑ Utility Notice No. of JULY 13, 2004 Fee Paid Deposit ❑ Agreement No. of $ 246 Performance Bond Amount(1) Payment Bond Amount(2) ❑ RIW Contract No. of $ $ Bond Company Bond Number(1) Band Number(2) TO: CHEVRON ENVIRONMENTAL MANAGEMENT COMPANYISAIC 3800 WATT AVENUE, SUITE 210 SACRAMENTO, CA 95821 ATTN : LEE HIGGINS TEL.: (916) 979-3781 I 1 PERMITTEE and subject to the following, PERMISSION IS HEREBY GRANTED to: Place a temporary soil boring approximately 50' below ground surface, using a direct push drilling rig. The location will be on State Route 33 at the southeast corner of State Route 33 and Welty Road. Upon the completion of work , the ground surface will be returned to original or better condition. Traffic control shall be accordance with the attached lane closure chart. A copy of this permit shall be placed in all vehicles involved in doing this work. In accordance with General Provision No. 6, SEVEN WORKING DAYS PRIOR to the start of this work, Permittee shall notify the State Representative MARCEL DE LA CRUZ, P.O. Box 2048 Stockton, CA 95201, (209) 948-3656. All work under this permit must meet with the approval of the State Representative. The following attachments are also included as part of this permit In addition to fee,the permittee will be billed (Check applicable): actual costs for: ® Yes ❑ No General Provisions ® Yes ❑ No Review ❑ Yes ® No Utility Maintenance Provisions ® Yes ❑ No inspection ® Yes ❑ No Special Provisions T ® Yes ❑ No Field Work ❑ Yes ® No A Cal-OSHA permit required prior to beginning work; # (!f any Caltrans effort expended) ❑ Yes ® No The information in the environmental documentation has been reviewed and is considered prior to approval of this permit. This permit is void unless the work is complete before JANUARY 31, 2005. This permit is to be strictly construed and no other work other than specifically mentioned is hereby authorized. No project work shall be commenced until all other necessary pe its and environmental clearances have been obtained. 1 -Permittee APPROVED: 1 -File 3—M. DE to CRUZ KOME AJISE, District Director BY: __.._. Joe LEO strict Permit En er 71131, FM 91 1436