Laserfiche WebLink
• 1-iV{YiC,I\'{\'{S'{S'fCISf\'f{'ii[{-[f'{\'fS-{\-{S'fi'{P,f'{S'{f'fi'{V{S' <br /> APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT is <br /> g UNDERC TO TANK r 1601 E HAZELTON AVE., STOCK CA r <br /> is CLOSURE*ABANDONMENT f: Telephone (209) 468-34e t <br /> C:"a :l�wwn:wwwn:www.:: :::::��: <br /> APPLICATION FOP. PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EMPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br /> XX REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE 1 CAC 000265553 PROJECT CONTACT 1 TELEPHONE 1 WiIliam wards - - <br /> _-- (209) 466-5371 — <br /> F FACILITY NAME Coit Drapery Service PHONE 1 (209) 466-5371 <br /> A <br /> C ADDRESS 1146 Enterprise, Stockton, CA 95204 <br /> 1 ---------- <br /> L CROSS STREET West Lane <br /> I <br /> T OWINER/OPERATOR William Edwards PHONE 1 (209) 466-5371 <br /> Y <br /> C CONTRACTOR NAME JIM THORPE OIL, INC. _ PHONE 1 (209) 462-4581 -- <br /> N CONTRACTOR ADDRESS 351 N. Beckman Road CA LIC 1 495699CLASS A, Haz. <br /> T - <br /> R INSURER On file NORK.COMP.1 on f i l e <br /> A -=-- — - -- ---=- - - --_ <br /> C FIRE DISTRICT City of Stockton PERMIT 111NSPTR <br /> 0 LABORATORY NAME FGL Environmental , Stockton, CA PHONE 1 (209) 942-0181 <br /> R - --- <br /> SAMPLING FIPMv same SAMPLING METHOD Brass tube-see #5 on removal Ian <br /> - X11= — <br /> TANK ID 1 TANK SIZE CHEMICALS STORED CURRENTLI CHEMICALS STORED PREVIOUSL <br /> T p 550 unleaded gasoline ( AL <br /> A 39-._� l_ L -` - <br /> N 39 <br /> K 39 _ <br /> 39 --------------------------- <br /> ---------------------------- <br /> 39 - <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P AImamluNmN�IW®a19MUW0aNWTARIggIgmqNMIwIN I <br /> PPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L fSEE T)1ACIIMENT NIT CONDITIONS) / <br /> A PLAN REVIEWERS NAME -- - G;./--` �d� ---------------DATE-_`4_sa -/ -------- <br /> N <br /> -- 111MUMFW111131111 I , I IDNNMNq®NINDIIIIDW�gNIImIUIWDAgIDpWIMIDIPgRIIgUqDYNNDC971G0Y7WpIppRpqlC@gIIINRIIIU➢IppIG71WGM' <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING,: '1 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING S16HATURE CERTIFIES THE <br /> FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA, <br /> CA ,R STIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED _ _ �l "---- - President- --- - -- ---- DATE 4/10/90 <br /> ---- -- --- ----------------en- ------------- <br /> OUTCE US ONLY-41I t3 0 6 It/I8 <br /> fffffifffffffffffiff{fffiffffffffffffiffiffffifffffffif{fftffffffifffffffffffff4fffftfffffffffffffffffffffffffiffifffffif <br /> SWEEPS 1 I COMP 1 LOC CODE JOIST CODE AMOUNT DUE I AMOUNT RCVD I CKI/CASH I RCVD BY 1=1_711 1 <br />