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etttxittt�textt oet:ttttoxtttx: :€exttextttactetwrxottx:x:x�zettt. Il•� CT <br /> t APPLfCATION�PEkMIi is SAN JOAOUIN LOCAL HEALTH DIST UNDERGRO TANK 1, 1601 E HAlELTON AVE., STOCKTOMt. y5(9&ayza <br /> CLOSURE OR ABANDONMENT t, Telephone (109) 468-3410 <br /> I989 <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAlARODUS SUBSTANCES,STR OEr17ACJE�TYcNLTH <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERk1 jYPE,;DE[Alj iVICES <br /> X4(_ REMOVAL ----- TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br /> 7ADDRESS <br /> 7100Block <br /> PROJECT CONTACT W TELEPHONE 1 Martin or Ric-fiar7- <br /> 171389Thorpe 462-458_1 <br /> f Lodi PHONE 1 (209) 333-6706 <br /> ---... ---- -------- <br /> of East Locust Street, Lodi , CA - Corner of Locust &.Main Street <br /> -- <br /> L CROSS STREET Main Street <br /> I --- <br /> 1 OWNER/OPERATOR <br /> Y City of Lodi PHONE 1 (209) 333-6706 <br /> C CONTRACTOR NAME Jim Thorpe Oil Inc. PHONE 1 - — - <br /> p i P (209) 462-4581 <br /> N CONTRACTOR ADDRESSCA LIC t CLASS A, Naz. <br /> T 351 N. Beckman Road, Lodi , CA 495699 — <br /> R INSURER on file WORK.COMP.1 on file <br /> C FIRE DISTRICT- Lodi — PERMIT 1/INSPTR -- ` <br /> T - _ __ <br /> D LABORATORY NAME Canonie Environmental <br /> R PHONE 1 (209) 983-1340 <br /> —_ --- <br /> SAMPLING FIRM, same SAMPLING METHOD Brass tube-see #5 on removal p an <br /> TANK 10 1 TANK SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> T 1 ,000 Diesel fuel <br /> A 39 � —UI - <br /> N 39 _ <br /> --------------------------- <br /> K 39 _ <br /> 39- <br /> 39 __ <br /> ---------------------- -- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P APPROVED __APPROVED WITH CONDITIONS DISAPPROVED <br /> (SEE ATTACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME <br /> N - DATE_ /���( ---------- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND RE60LATIONS <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 /> SUIJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TD MA'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPEC IONS AT LEAST 46 HOURS IN ADVANCE <br /> SIGNED_--- <br /> --- Iir-ez.JlnesidanL-----------------—DATE <br /> .... 14L$4 -- <br /> Uffltf USE 0 P--fN 1J O$6 INS <br /> /// �5. <br /> i{{f{f{ffff{ ifffiftftfiffffftfft{ffffffffffftffffftf{ff{fft{ff{fffftffif{{tftt4f{tf{ftfffl{ff{ftftfiftfffffffftftfffit{f <br /> $YE3P ,t LUMP 1 LOC CODE I DIST CODE ^AMOUNT DUE I AMOUNT,R�VD III,. CKt/CASH I RCVD tY I DATE RCVD PERM�1 <br /> �uzrsasa <br />