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e tt9ItI..:R Rt•tti.tIttlttPtt;LtttRtCtCFtM'Et'tt�CCtTirY3C t{ <br /> t APPLICA FOR PEiA1SAN JOAQUIN LOCAL HEALTH <br /> UN D .JUNp TAN). k 1601 E HAIELTON AVE., SYL, CA <br /> t CLOSURE OR�ABANDONMENI t: Telephone (209) 468-3120 : <br /> ::«':«':«':«i«':«:«'::►7 ?YI«.�«.!):!«:�).N wY q'gC1Y 1):►)'►):i i)►).q:1)i)1]'N►Y. <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAIARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE 6ELON: <br /> _XX REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> }; � EPA SITE ti ''AD 009109844 -• _-~-- _ .PROJECT CONtAC1 t-TELEPHONE-r--�.Gra _-(-20�9) 466-'Z041 <br /> Q <br /> • ` ; F ' FACILITY NAME Pure ro Company PHONE---- A <br /> A (�_ 9 P y (209) 466-2041 . <br /> � C � ADDRESS 1904W._ Charter Way, Stockton,- CA--- -- -�--- <br /> L CROSS STREET Fresno Avenue _ <br /> T OWNER/OPERATOR pure ro Company PHONE # <br /> 9 P (209) 466-2041 <br /> Y <br /> ' i' 4 CONTRACTOR NAME Jim Thorpe Oil , Inc. PHONE # _ (209) 462-4581 -'- <br /> O <br /> N { LONTRACIO?, ADJoESs �5l N. Beckman Road CA LIC t _495699 �CLASs A, Haz <br /> 44 T F— ' <br /> R ( INSURER on file ---�.rM . WORY,.CONP.t . <br /> C FIRE DISTP.IC' San Joaquin -� _ j PERMIT I/INSPTR --y �-� -r-- <br /> T <br /> .0 LABORATORY NAME FCL Environmental PHONE # (209) 942-0181 <br /> SAMPLIN5 FIRM' same SAMPLING METHOD Brass Tube-See #5 on removal Plan <br /> s TANK (D t TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUS <br /> T 1 ,000 Unleaded oas <br /> A � I/—� � � <br /> ----- -- - ---- 1 (100 __-- Unleaded gas ----_-- _ <br /> ----- <br /> r ---- -- - ---- <br /> ---------- <br /> --- <br /> 39--------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P _ _ APPROVED APPROVED WITH CONDITIONSDISAP <br /> _ PROVED <br /> L EE ATTACHMENT H CONDITIONS) - <br /> _ <br /> A PLAN REVIEWERS NAME -------��--1/ --- --------------- ----------------DATE_ _ <br /> N --- <br /> a <br /> " /;PPLICANI MUST PERFORM, ALL WORK IM ACCORDANCE WITH SAN )OAAUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATION; <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH .4ANNER AS TO BECOM <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONIRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FCLLOWING: 'I CERTIFY THAI IN THE PERFORMANCE OF .THE WORK FOR-WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> TO HORKER'S COMPEIISATION LAWS OF CALIFORNIA. <br /> '.: -CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> Vice-PresidentDATE 2/2/90 <br /> vWGfF/fE OSE 0 LY--EM 23 016 12/88 �j <br /> :f . <br /> - ---------------- <br /> - ssiitssttssssttssstsststsssssssssisstssssstsssssssssssssssttsssssstsssssssssssssttssttttstssscssssssssssssstsssssssssttsts <br /> y.. . { DATE RCVD PERMIT # <br /> WtEPS 1 COMP # )LOC CODE �OISi CODJ� AMOUNT DUE�AMOUNT RCVD CK#/CASII RCVD BY <br />