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APPLICATION{ PERM II SAM JOAQUIN LOCAL HEALTH DIST r, C <br /> UNDERGP' 'I TANK 1601 E HAZELTON. AVE., 'STOCKT�� <br /> t: CLOSURE 6w4ANDONMENT Ielephone (209) 4W-34r- <br /> t: <br /> 1F <br />� � �n:a:'x'r.►a:�s:Axa:u:uxu:u:�xrs:�i;��:�:�x►i:►s:u:a:�xn:n:.s:�ru:rxrx,►x�x <br /> J YwY wY wY ww w.•Yw•�._••.•w•• •• yw• ••ww•w•w • •Y.wY•.•_.• <br /> APPLICATION FOP PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED''''AREAS, ;�.INDICATE PERMIT TYPE BELOW. <br /> REMOVAL _ TEMPORARY CLOSURE ABANDONMENT IN PLACE - <br /> f EPA SITE i CAC 0001914$3 PROJECT CONTACT I TELEPHONE # a or c horpe <br /> (209) 462-4581 <br /> I F FACILITY NAME CECO Building. Corp. PH©NE # {2090 727-550 <br /> A <br /> C ADDRESS <br /> 12101 E. Brandt Road, Lockeford, 'CA Aj <br /> Iz <br /> L CROSS STREET Hwy. 8817 1 9 19F 9 <br /> i <br /> ENVi?ONv E v,AL I- AL#H <br /> T OWNER/OPERATOR Ceca Building Corp. PHONE # I :' P_ar,n r I c D ir F- <br /> it <br /> Y Gerry Gandt i{ (209) 727-5504..__. — <br /> C CONTRACTOR NAME PHONE I ° <br /> Jim Thorpe Oil , Inc. 209:1 462-4581. <br /> P i� <br /> N CONTRACTOR ADDRESS 351. N. Beckman Road, Lodi , CA CA LIC 1 4956:99 CLASS A, Haz. <br /> T <br /> R INSURER on file WORK.COMP II on, f i l e <br /> A. - --- .�. .. �_. -- <br /> C FIRE DISTRICT San Joaquin County PERMIT IIINSPTR <br /> T <br /> O LABORATORY MARE Canonie Environmental PHONE # (209) .983-1340 <br /> SAMPLING FIRM* sameAMPLING METHOD Brass Tube-See5 an Removal I} anis . <br /> f i w <br /> TANK 10 T. TANK SIZE CHEMICALS STORED CURB°ENTL CHEMICALS STORED PREVIOUSL <br /> T <br /> 39- 12,000 Unleaded Gas same <br /> A _ � �G I----------- <br /> 12,000 Diesel Fuel same <br /> --_------ <br /> 31-___ 3G3-6`_ ___ 2,000 Diesel Fuel same <br /> ------ <br /> -, - --- ---} LIST ADDITIONAL TANK INFORMATION AS';�NEEDED'ON SEPARATE FORM <br /> P APPROVED APPROVED WITH CONDITIONS ._:f_ DISVPRAVED . <br /> L (SEE ATTACHMENT RLTH CONDITIONS) <br /> A PLAN REVIEWERS NAME ---------------------------- -------- ---------------- !f ._DATE ---------------------------- <br /> 14 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES; STATEFLAWS, AND RULES AND REGULATIONS <br /> IIF THE SAM JOAQUIN LOCAL HEALTH DISTRICT. oOMER 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 SUSCONTRACTING.SI6NATURE 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 /> k CALL FOR INSPECTIONS AT LEAST 413. H0URSiINWDVANCE <br /> SI6MEIF - ------- -Vice--President DATE ---I1.1 .L8.3 --------- <br /> OFFICE - <br /> ..USE OMi9- 5 23 !E'tllii� - -;j-- -,k <br /> fffffi3ifi#iffSfi#isttffi3iififiiifiiififfiffififfifiiffiffi#iiiiifiiffifiiiiiiifffiii#{fffifiiffiisififiSiiiffiiffiff <br /> SWEEPS I :COMP # LOC CODE DIST CODE AMOUNT DUE L=!UNT RCVD .I CK#/CASH E RCVD IV DATE RCVD PERMIT # <br />