Laserfiche WebLink
tit I tt ti-ttt tit tit It it It t it R.it it ti it t t it it it it it it itt " ttt �qD� <br /> _ t APPLICATIdWR PEkMIT t: SAN JOAQUIN LOCAL HEALTH D1gT Y <br /> f p UNDERGROUND TANK t 1601E NAZELiON AVE., STOCY,TO CA t. <br /> t CLOSURE OR ABANDONMENT t: Telephone (209) 468-3420 t <br /> ....................... ft.2y: <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBST41oS ST FAC // <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS, INDICATE PERMf,T 3YPE `110.{: V*�, <br /> X REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE t CAC 000168269 J PROJECT CONTACT 1 TELEPHONE 1 Martin Thorpe_ (2 ;46 -4581 <br /> F FACILITY NAME PHONE 1 <br /> A _ Herbert Ostermann A (209) 369-3176 <br /> C ADDRESS 705 N. School Street, Lodi , CA <br /> 1 - <br /> L CROSS STREET Forest Street <br /> 1 -- — <br /> T OYNER/OPERATOR Herbert Ostermann PHONE 1 (209) 369-3176 <br /> Y <br /> C CONTRACTOR NAME PHONE 1 <br /> O Jim Thorpe Oil , Tnc. --_ (209) 462-4581 _ <br /> N CONTRACTOR AODRE53 351 N. Beckman Road, Lodi , CA CA LIC t 495699 CUSS A, Haz. <br /> T — <br /> R INSURER WORK.COMP.1 on f i l e <br /> A -- on file <br /> C FIRE DISTRICT Lodi PERMIT l/INSPTR <br /> T <br /> 0 LABORATORY NAME Canonie Environmental PHONE 1 (209) 983-1340 <br /> R — <br /> SAMPLING FIRMtrAnnnip nvironmental SAMPLING METHOD See #5 on removal plan <br /> LREVIEWERS <br /> ANK 10 1 TANK SIZE CHEMICALS STORED CURRENTLYCHEMICALS STORED PREVIOUSL <br /> 275 Regular Gasoline ri <br /> _O <br /> — - <br /> -------------------- <br /> - <br /> -------------------- <br /> --------------------- <br /> - <br /> -------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> �--/- --- ---- <br /> EWERS NAME ___� . iISEE ATTACHMENT YIfH CONDITIONS <br /> ---------------------------------------DATE. � �----------------- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF TINT 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, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS 1O 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 /> TO YORKER'S COMPENSATION LAYS OF CALIFORNIA. <br /> CALL FO I LEAST 49 HOURS IN ADVANCE <br /> SIGNED___-___ Vice-President - - - _DATE___4/20/89 <br /> OFFICE ISE LY 23 116 IS/ <br /> {{itfitt ftftfifttfffftfttffi fNtfftft fffiffitifftifi{fiitfffttffffitttNftffN{tfftftfiffifftt{ffitffttNt4ftff <br /> 9MEEPS 1 COMP 1 LOC CODE 0 1 CODE T DUE AMOUNT RCVD CKI/CASH RCVD BYP� DATE RCVD I PERMIT 1 I <br />