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4t4't4N44e� _41:A914 W t4t4 tY t404th:'04 t4tt t4:0 0: It tvtlV 0,kv <br />F APPLICATIW FOR PERMIT F SAN JOAQUIN LOCAL HEALTH 07%010t. <br />r UNDERGROUND TANK 1: 1601 E HAZELTON AVE., STOCKTON CA t. [ e <br />t: CLOSURE OR ABANDONMENT Telephone Telephone !2091 468-3420.04 �` C�{ <br />:T1:x.r.lx;r.lr.;s: <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAIARDOUS SUBSTANCES STORAGE FACILITY <br />THIS PERMIT EXPIRES 901M FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW. <br />_ x_ REMOVAL _____ TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br />EPA SITE 1 CAC 000202573 <br />— __---.__— (209) 462-4581 <br />PROJECT CONTACT M TELEPHONE 1 Rich or 19arty horpe <br />_ _ <br />F FACILITY NAME Best Cleaners <br />PHONE / (209) 369-2865 <br />A <br />C ADDRESS 541 N. Hutchins, Lodi, CA 95240 <br />--- <br />1 <br />L CROSS STREET California Street <br />- <br />I <br />T OWNER/OPERATOR Kyo S. Pang <br />PHONE 1 (209) 369-2865 <br />Y <br />C CONTRACTOR NAME Jim Thorpe OI1, Inc. <br />PHONE 4 (209) 462-4581 <br />- -- <br />D <br />N CONTRACTOR ADDRESS 351 N. Beckman Road <br />CA LIC 1 495699 <br />CLASS A, Haz. <br />T — <br />R INSURER on file <br />WORK.COMP.1 on file <br />A_— <br />C FIRE DISTRICT City of Lodi <br />PERMIT B/INSPTR <br />T <br />0 LABORATORY NAME Canonie Environmental <br />PHONE 1 (209) 983-1340 <br />R <br />SAMPLING FIRM, same SAMPLING METHODbrass tube -see <br />#5 on removal p <br />TANK 10 1 TANK SIZE CHEMICALS STORED CURRENTLYCHEMICALS <br />STORED PREVIOUSL <br />A 39-_�_s_ _Q_L__ 550 solvent <br />_— <br />N39---------------------------- <br />— <br />K 39- <br />9 --' ---------- --- <br />------------------------- <br />39- <br />39 --------------------------- <br />- ------------------------- <br />---------- <br />-------------- — ----------- LIST <br />UST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE <br />FORM <br />P _ APPROVED _—APPROVED WITH CONDITIONS ____ DISAPPROVED <br />Ly0 (�SEE"" A'�1IAC��ZINENI WITH CONDITIONS) <br />A PLAN REVIEWERSNAME --___,mac '---------------------- OAiE-_-_`� 1_¢_- ------ <br />N <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,: 'I CERTIFY THAT <br />IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 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 SIGNATURE CERTIFIES THE <br />FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUIJEC <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br />CALL FOR INSPECTIONS AT LEAPT 48 HOURS IN ADVANCE <br />SIGNED `Vice President 9111E-- 8/28/89 <br />— --- ----- ------*� --�--- - - — --------- <br />OFFICE as ONLY -411 IJ 046 I2/18 .?m. <br />fltf{4fffffltt{lffff{ftifffiSifttf{fffff{{{f{ffffiff{{!{1ff{ff{fN{If{{ff{fffff{f{fff{f{fff{{{ff{{1{tfffffftttftft{t{fflf <br />EPS COMP # LOC CODE DIST CODE AMOUNT DUE AM NT RCVD CKIlCASH RC BY DATE RCS PERMIT 1 <br />o� <br />in <br />