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t R ft R:Rr tl:ffR:tt:tt ttt:R R H R.tt ,Lt t tt till: /�eJ coPi <br /> t: APPLICAA FOR PERMIT t: SAN JOAQUIN LOCAL HEALTH SRICTt: <br /> t: UNO UND TANK t: 1601 E HAZELTON AVE., STO N CA t: D $� <br /> ` t: CLOSURE OR ABANDONMENT t: Telephone (209) 468-3420 V ff <br /> ' ::'::'::'::'::'::'::'t:':::'::'::': '::'0::�.�.�...�..�....}.::':::mak:.3-.311'::' 1,.}..3- <br /> td� <br /> 4—�—t1 ?� <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES SJJTORAG ElAC a TY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE[PERO.JT; P W}ir, iTII <br /> '/ <br /> L__ REMOVAL ----- TEMPORARY CLOSURE _--_ ABANDONMENT IN PLACE PEI2A;11iSEI&lCES <br /> — EPA SITE #� PROJECT CONTACT TELEPHONE #CAC 000146781 f I0avid Chavier (209)V941 - 1444 <br /> F FACILITY NAME Vacant (Old Butcher Shop) PHONE # <br /> A <br /> C ADDRESS 1210 E. Victor Road , Lodi , CA <br /> I <br /> L CROSS STREET Cl uff r <br /> I _ <br /> T OWNER/OPERATOR Bank Of Stockton PHONE # (209) 941 -1444 <br /> Y P. 0. Box 1110, Stockton , CA 9520 <br /> C CONTRACTOR NAME Jim Thorpe 011 , Inc . PHONE # (209) 462-4581 <br /> 0 -- <br /> N CONTRACTOR ADDRESS 351 N. Beckman Road CA LIC # 495699 CLASS A, Haz„ <br /> T <br /> R INSURER on file WORK.COMP.# on f i le <br /> A =- — <br /> C FIRE DISTRICT Lodi JP�ERMIT #/INSPTR� <br /> 0 LABORATORY NAME Canonie Environmental T <br /> �� PHONE # (209) 983-1340 <br /> SAMPLING FIRM* CC,+I "n:Yl I�'_`-' L- o V/ J AMPLING METHOD <br /> --I VuuuuuWgWUluuuggqulquWquNqluul�uuqluqWuqlgquwwulqulu b rcc s S ---u% c-- <br /> T <br /> TANK 1D # TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSL <br /> � <br /> A 33- �� _ 500 l.Jnleaded Gas Unleaded Gas <br /> N 39- <br /> ............................ ---- <br /> K 39- <br /> --------------------------- — - <br /> 39----------------------------- <br /> _39--39--------------------------- <br /> ------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> IggV6NUgWWllUqItlCNIIUIQdIWqIWfIqU#ggWNgWWI#qlqqlqN9qGl�l tlNglgg9qqI�UIIqIWqll@IgggOqqWqWBqNmqUqVdqlqqll gVY9#glgglqWqllllgqlqqqNqlqlqlW�WBIIWWqqlqUqlliGiqqWGqlYqlqlNqIVWYIIqINlqqqqqqqWlqqqqlqWlqllqlldqqVNNqWqqllqlqqlllqll! <br /> P APPROVED ---APPROVED WITH CONDITIONS DISAPPROVED i <br /> L (SEE ATTACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME <br /> ---� -- ----------------------------------------DATE__ Z 1_ - ----- <br /> N -------- <br /> , <br /> - Iq�IWOGItlgIVldBggglqqG#IWWUIVH9gIIWgIgIWNGVqNNUWIWIIqquqqqqqqVqWIVIVIWNWqlqliqlVWgqWIlVlqqqqlWqqBIIIqIVNqCplqqlqlWVII�IVWWVqWWNWIIqIqWWWdI{WIVWggglqqqqqlVq9qYqWqqqlVlqtlU�WgIIWUVWIgIWWNgIINqVWIIIqIIIVIWqCqq <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, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <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, I SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALLF CL,. EETLQ�+IS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED__- _ �_ / ' Vice_President DATE 1/31/89 <br /> --- - -- ------------------------- --------------------------- <br /> OFFICE .IISE ONI --EH 13 0 4 11/88 <br /> ffffffffifffffifffffffffffffffffffffffffffffffffffifffffffffffftfff.ffffffffffifffffffffffffffffffffffffffffffiffffffff <br /> SWEEPS # COMP # BLOC CODE DIS ST CODEI AMOUNT vDUE _AMOUNT RCVD CK'#/C{. I RCV DATE RCVO I PERMIT # <br /> --I L__._�_ j <br />