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{f I{t'{{{i'\[Y(l{t{i{{'{t{t'{t 1% Ilk'It'[{'[t[t tt'It'.['{{[.'t•\i\\'{.{1' <br /> t' APPLICA FOR PERMIT t' SAN JOAQUIN LOCAL HEALTH RICTV <br /> K INDE UNO TANK t: 1601 E HAiELION AVE., St0 1 CAt <br /> i <br /> CLOSURE OR ABANDONMENT t: Telephone (209) 468-7120 Y <br /> tZlZ'!Z:'.'tZ°tZLZlZ:ZftlZlZtZlZli'!ZlZtZt:lYK <br /> APPLICATION FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAIARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT IVPE BELOWt <br /> _ REMOVAL ..... TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br /> EPA SITE ICAC 000552416 PROJECT CONTACT i TELEPHONE-I Jim Thorpe Oil 368-6175 <br /> F FACILITY NAME Brayton and Sons Inc. PHONE 1 (209) 838-7388 --- <br /> A - — <br /> C ADDRESS , Escalon, Calif. 95320 <br /> 1 1745 Second St. .._----_---- <br /> L CROSS STREET Jackson - <br /> I OWIIERIOPERATOR PHONE 1 <br /> Y sarne as 1?n4) mF1 7"168 -- <br /> C CONTRACTOR NAME T PHONE 1 - <br /> 0 -- _- Tim Thorne Oil Inc -- <br /> N CONTRACTOR ADDRESS CA LIC 1 CLASS <br /> _ _ '151 N. Beckman rd Lodi Ca. 495699 A R z <br /> R INSURER on file WORK.COMPJ On file <br /> A ------- <br /> C FIRE DISTRICT PERMIT I/INSPIR <br /> I -- -_-_Escalon - _--- — <br /> 0 LABORATORY NAME - 1 Water Works PHONE 1 (209) 838-3507 <br /> _ L <br /> R — - - <br /> SAMPLING FIRM, SAMPLING METHOD brass tube-see N5 on removal p an <br /> e - <br /> TANK 10 1 TANK SIZE CHEMICALS STOPED CURREMILI CHEMICALS STORED PREVIOUSL <br /> 1 550 gal. Diesel Diesel <br /> A 33 lYys_=0 -------- <br /> 0 39--•-------------------•----- <br /> 0 39- --- — -- - <br /> 39 — <br /> 39---------------------------- -- — <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P ___- APPROVED _APPROVED WIN CONDITIONS __-_ DISAPPROVED <br /> L ISEE ATTACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME -______ __ rp[ .................................DATE___ -_t f___ !__.________- <br /> N <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WIIH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANO REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING1 -1 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 DECOR <br /> SUBJECT 10 WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S MIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWINGt 01 CERTIFY THAT IN 111E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS Of CALIFORNIA. <br /> CALL ?10)(,INISP7710 ATLEA3T 4E3 HOUR3 IN ADVANCE <br /> SIGNEDDATE-_1 <br /> DFF►C ISE NlF -E16IJ <br /> IIIIHIIHIII►►IIH►H►{►►Iltlt►►H►NH►NIHI{►►H H►IHItIH►HI►N►N{►I►HHIf►fNHN►{►If►t►►►H►►1►{H►{►►1►TIN <br /> SWEEPS 1 I COMP 1 ILOC CODE JOIST COOED AMOUNTDUEI AMOUNT RCVD I CKIICASH I RCVD BY ` DATE RCVB PERMIT 1 <br />