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H. <br /> ` ENVIRONMENTAL HEALTH DIVISION , <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE _ ABANDONMENT IN PLACE <br /> EPA SITE # Gk cvo*! r� 64 PROJECT CONTACT & TELEPHONE # Martin Thorpe (209) 368-6175 <br /> PHONE # Nene <br /> F FACILITY NAME Babka Distributing <br /> A <br /> C ADDRESS 1245 W Weber Ave. Stockton Cal. <br /> I <br /> L CROSS STREET Edison St. <br /> IPHONE # (209) 941-1220 <br /> T OWNER/OPERATOR Bank of Stockton <br /> Real Estate Dept. <br /> Y <br /> PHONE # <br /> C CONTRACTOR NAME Jim Thorpe Oil Inc. / D.B.A. Rich-Mart Const. 20 368'-61 <br /> 0 351 N. Beckman RdCLASS <br /> CA L IC #4 56 A/R Eiaz. <br /> N CONTRACTOR ADDRESS <br /> Po. Bx. 357 Lodi. Cal. 95241-035 <br /> T WORK.COMP.# <br /> R INSURER On File On F' <br /> A PERMIT # <br /> C FIRE DISTRICT City of Stockton <br /> T 7�1,60 fI'i/!W re'v1- <br /> 0 LABORATORY NAME Water Works ` �/�/ / PHONE # (209) 838-3507 <br /> R Z/f T',/'-,/E's EPHONE # ,,a� /f/S L L J C7l� <br /> SAMPLING FIRM same <br /> IIIIIIIIIIIIIIIIIIIlIIIIIIIIII TAN SIZE CH IGALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK [p # ! 10 M Gals. Unleaded Gasoline 7 Z-- <br /> 39 Zr�Dd J 7 v <br /> T 39--Z-POO Z <br /> A 39- <br /> N 39- <br /> K 39 <br /> 39- <br /> 39- <br /> Illllll111111i1111111111111111 111111111111111111111111111111! 11111Ililllllillllllllli111111l1!lII111 Ililllllllllll1111lI <br /> P <br /> L APPROVED APPROVED WITH CONOITION(S) DISAPPROVED <br /> A ( //A''TTACHMENT WITH CONDITIONS) 3% <br /> N PLAN REVIEWERS NAME- <br /> - <br /> AME_ ILC DATE ._ <br /> III 111111111111111111111111Ill 011 111Illllli1611111111II11111111111IIIllllllllllllllliilllilllllllil�llIII 11111111 ill <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN 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 CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> TITLE DATE <br /> APPLICANT'S SIGNATURE: <br /> EH 23 046 (Rev 2/8/91) ft Page Z' <br />