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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISIP,ICT r <br /> r UN GROUND TANK r 1601E HATELTON AVE., STDPY,TON CA 1: r/ <br /> 1: CLOSWOR ABANDONMENT r Telephone (209) 4*0 r /! e <br /> ::'.tyfftt:t'!L.1It:n:a.....tars:::!.....t:.n..1 m...ttat:Y::::.t. <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE t ---I PROJECT CONTACT 1 TELEPHONE 1 Gene Vanderplaats <br /> CAC 000280913 L 209 599-4209 <br /> F FACILITY NAME Ripon Fire Department PHONE t (209) 599-4209 <br /> A -- �------ -- <br /> C ADDRESS 142 S. Stockton Avenue, Ripon, CA 95366 - � V <br /> T — ---- -- --- itsII, <br /> L CROSS STREET West Main Street <br /> t -- -- -- <br /> T OINIER/OPERATOR PHONE 1 990 <br /> Y _ _ same <br /> ENVIRONMENT HEALT' <br /> C CONTRACTOR NAME Jim Thorpe Oil , Inc, PHONE 1 (209) 462-4581 or 368-6175 <br /> i CONTRACTOR ADDRESS 351 N. Beckman Road, Lodi 6L 4U CA LIC 1 495699 CLASS A, Haz. <br /> R INSURER on file NORK.COMP.t on f i l e <br /> A _ _----_=--- _ _= _ --_-- - --.-..- - ..-... <br /> ----- <br /> C FIRE DISTRICT City of Ripon l PERMIT I/INSPTR <br /> D LABORATDRY NAME Canonie Environmental IPHONE 1 (209) 983-1340 <br /> R --------- L <br /> SAMPLING FIRM' same SAMPLING METHOD brass tube-see N5 on removal p an <br /> LANK ID 1 TANK SITE CHEMICALS STOPED CURRENTL CHEMICAL TORED PREVIOUSL <br /> T <br /> A 39-__ IVeo_-. i/ 550 --- unleadedgasoline <br /> N 39 <br /> - <br /> K 33 ---- _ -- <br /> --------------------------- <br /> 39 - <br /> ---------------------------- <br /> - <br /> 3 3 <br /> - LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> NOO�IINttIpbt �A�l�p�BlpR�pl�AdPN1�NIlAYR�I�W49@�ai00pBWpgR�l <br /> P APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> ( (SEE ATTACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAMES/ DATE- <br /> N <br /> --hem F noMBNN®tl9MtlN1 DT01tlR�ApBWP01DMBMWBED BBIBOW110WRP BIWA7IYBHAIBGGOPXNVIIO�NNI <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, 1 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECT ONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED----- <br /> DATE <br /> 1O{FIFt{TC1E{{B{SIEllO{-N-1f-f�-{-{EiN1{-1IJf-{0f-f16-l{f-ftf-f/BfB{fillflf-l-�if-fff <br /> if{fV1i{Icfefi-{Ptrflelsf{i{dfe{{nttff{fit{{f{f{{t{fififitffff{tf6{/{f7{/{f9f0_ - -----------1 <br /> -f-{-f-{-{-{-i-f-f-f-f- <br /> SWEEPS {-f-{-f- <br /> t <br /> 1 I COMP 1 ILOC CODE (DIST CODE AMOUNT DUE I AMOUNT RCVD I CKI/CASH I RCVD BY - D� ATE RCVO PERMIT t <br />