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r--,.,►,~moo <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATICH FOR UNDERGROUND TANK CLOSURE PERMIT S <br /> 19 1 <br /> APPLICATION FOR PERMANENT/TEMPORARI CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANC��,01-- E'F C TY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> CE u:,'•:"���� I��� �'E"�LTH <br /> ABANDONMENT 1N PIA <br /> X REMOVAL TEMPORARY CLOSURE ES`' r j R <br /> EPA SITE A CAC 000612672 PROJECT CONTACT S TELEPHONE # Richard Thor e (20 368-61 5 <br /> # 94b-0246 <br /> F FACILITY NAME Port of Stockton PHONE (209) <br /> A <br /> C ADDRESS 2201 Washington St. Stockton, Calif. 95201 <br /> I <br /> L CROSS STREET Fresno Ave. <br /> I PHONE # <br /> T OWNER/OPERATOR <br /> Y Port of Stockton. Same as above <br /> PHONE A <br /> C CONTRACTOR NAME Jim Thorpe Oil Inc. / D.B.A. Rich-Mart Const. 20 68-6 <br /> 175 <br /> 0 1 N. Beckman Rd CLASS <br /> N CONTRACTOR ADDRESS CA LICA A B Ha Z. <br /> Po. Bx. 357 Lodi Cal. 95241-035 4 5b <br /> T WORK.COMP.A <br /> R INSURER Firemans Fund / Admiral 1095135-90 <br /> A PERMIT # Fire permit will be <br /> C FIRE DISTRICT city of Stockton r3 ylPyC1Y7 rin.nl <br /> T PHONE A <br /> 0 LABORATORY NAME Weston Analytical (209) 983-1340 <br /> R PHONE A <br /> SAMPLING FIRM Same as above Same as above <br /> llllllllllllllllllID 0lll[lll[lll TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 7 <br /> T 39- � - d __2Qga raj------ <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> IIIIIIIIIIIIIllll1111111111111 Illllilllllllllllllil11111111 [11111111111111111111111111111111111111 1lllllllll1111lllllll <br /> P DISAPPROVED <br /> L APPROVED _ APPROVED WITH CONDITION(S) <br /> A f(SE A T ENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME &J DATE ! / <br /> IIIIIIIIIIIIIIIIIIIIlI11 llIIIII[Illllll[lllllllllll[Illllllllllllllllllllllllll[lllllllllllllll111 IIII lllllllllllllllll! <br /> APPLICANT 14UST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIH COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIAUCONTRACTOR'S <br /> PERMTTHIRING <br /> 1SSUEDSUBCONTRACTING <br /> EMPLOYSIGNATURE <br /> PERSOHS SUBJECTCERTIFIES <br /> TOTWORKERHE LC�IItNG: <br /> ""I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR HICH <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> TITLE Contractor DATE 7/1/91 <br /> APPLICANT'S SIGNATURE: <br /> EN 23 046 (Rev 2/8/91) ft Page I <br />