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t: APPLICATION FOR PERMIT K SAN JOAQUIN LOCAL HEALTH DISTRICT N <br /> N UNDERG UND ZANY, N 1601 E HAIELION AVE., STOCKTON CA u�h'-L,t: CLOSURBWABANDONMENT t: Telephone (109) 160-5 F <br /> tttttttIt'oftttttttttltttttit:ttttft'tttt'tiff tt:tttttrot ItttttttttIt* <br /> APPLICATION Top, PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAiARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EIPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOWt <br /> _ REMOVAL TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br /> — EPA SITE I CAC 000552416 PROJECT CONTACT TELEPHONE 1 Jim Thorpe Oil 368-6175 <br /> F FACILITY NAME Brayton and Sons Inc. PHONE 1 (209) 838-7388 <br /> A --- <br /> C ADDRESS 1745 Second St. , Escalon, Calif. 95320 <br /> 1 ——---- <br /> L CROSS STREET <br /> I Jackson — <br /> T OWNER/OPERATOR PHONE 1 <br /> Y <br /> Sama asa_h_n_vP_______ <br /> C CONTRACTOR NAME T PHONE 1 <br /> 0 --_---_-- Jim Thorpe Oil Inc, - — - <br /> 61 <br /> N CONTRACTOR ADDRESS CA LIC 1 CLASS <br /> 1 __ 351 N. Beckman rd Lodi. Ca. 495699 A B Haz. <br /> R INSURER on file WORK.COMP.1 On file <br /> A - _=-- --------- ---_=-_- <br /> C FIRE DISTRICT PERMIT 1/INSPIR <br /> Escalon �1___- - <br /> O LABORATORY NAME Water Works —1PHONE 1 (209) 838-3507 <br /> R — <br /> SAMPLING FTRMt SAMPLING METHOD brass tube-see N5 on removal p an <br /> _ e <br /> TANK ID 1 TANK 511E CHEMICALS STOPED CURREMILI CHEMICALS STORED PREVIOUSL <br /> T <br /> 550 gal. Diesel Diesel <br /> N 39 <br /> --------------------------- <br /> K 39 ----- - <br /> --------------------------- <br /> 33 -- <br /> --------------------------- <br /> 39 - <br /> --------------------------- <br /> ---- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P APPROVED APPROVED WITH CONDITIONS DISAPPROVE) <br /> L )SEE ATTACHMENT WITH CONDITIONS) <br /> A PIAN REVIEWERS NAME .................................................DATE.....------------------------ <br /> N <br /> APPLICANT MUST PERFORM ALL YORK IN ACCORDANCE PITH 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 FOLLOWINGt 'i CERTIFY THAT <br /> IN THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO IECOM <br /> SUBJECT TO YORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOVINGt '1 CERTIFY THAT IN THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO YORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL O )NSP IO ,AT LEAST 48 HOURS IN ADVANCE <br /> S I GNE T . .4�5"'r............. <br /> OFFIC ITT NtF--11 JJ TIE IJ/1 <br /> Iloilo It 11111{INIIIINii1{HN{NIN{IIItiNI{1{{N{HIIfIII1IHFIHNHNI <br /> SWEEPS I ILOMP ITIDISI t00EJ AMOUNT DUE ��15NTRCVD I `KIICASN I RCI T DATE R VD PERMIT 1 <br /> Lz <br />