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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDEW1GROlRID TANK CLOSURE pERNti <br /> + <br /> APPtTCAt1ON FOR PERHANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE Of UNDERGROUND HA2ARDOUS "SIS Rj VIgq �FACILITY <br /> THIS PERMIT EXPIRES 9() DRYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE�P-ERMIT TYPE BELOWS <br /> If.'i�{VITAL I IEA_ H <br /> XX REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE 0 IIT13LRVIC'= <br /> EPA SITE +F CAC 0006125600 PROJECT CONTACT & TELEPHONE 0 Richard Thorpe 2 <br /> I FACILITY NAME M L. Greriz <br /> A (209Y 36 - 0 <br /> C ADDRESS 6540 E. Jahaunt Rd Acampo, Calif. 95220 <br /> U CRoss siaEEt Kenifeck <br /> 1 <br /> 1 OWNER/OPERATOR PHONE 0 <br /> r Same as above Same as above <br /> C CONTRACTOR MAHE Jim Thorpe 011 Inc. / D.B.A. Rich-Mart Const. PHONE 9 (208-6175 ' <br /> ° 351 N. Beclanan Rd <br /> H CONTRACTOR ADDRESS Po. Sx. 357 Lodi Cal. 95241-03571 CA LTC #495699 <br /> CLASS A $ LLaz. <br /> T <br /> R INSURER F'irEwins Fund / Admiral WORK.COMP.B 1095135-90 <br /> A -- � <br /> C ETRE p14TA1CT Lzberty PERMIT *Fire {}erTnit 1.ri11 be <br /> ABORATOtY NAME Weston Analytical PHONE 0 (209)983-1340 <br /> � <br /> R <br /> WLIN" <br /> III}11111111111 111 VO PHONE It S8TT1E as above . I <br /> INK ID TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39 260 gal. leaded ga,3oj_jue <br /> A 39 <br /> N 39- <br /> K 39 <br /> 31 <br /> 39 <br /> #f1i#1111#1111#I#I###11#1##III I#Ii#I#11#lill#IIIIIIIIIIII#I#It ##I##I#I#I#III#1#II11111111#II#11111#fl IIII#tI1111I1lI##111# <br /> L / APPROVED APPROVED VITH CONDITIONS) DISAPPROVED <br /> ! /r— (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME �f�f✓Y } � - - - - _ DATE 7 ; g <br /> #1111111111111111111111111111111 it l 1111 i1I 1I lI1111II 11 111111111l 111111111 11111111111111111 fill 1111 III 11111111111111111111 <br /> APPLICANT HUS? PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN tOUHTY PUBLIC HEALTH SERVICES OWNER OR LICENSED AGEHTfS SIGNATURE CERTIFIES THE FOLLOWING: 4 CERTIFY THAT IN <br /> THE PERFURHANCE 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 "tER'S COMPENSATION LAWS OF CALIFORNIA " CONTRACTORI'S HIRING OR SIUSCOMIRACT140 SIGNATURE CERTIFIES THE FOLLOWING, <br /> "I CERTIFY THAT IN INE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORXER'S <br /> 0INSATION LASTS Of CALIFORNIA," <br /> APPtICAYfft SIGNATURE$ TITLE Contractor VATE 6/28/91 <br /> EN 23 046 (Rev 2/8/91) It Page <br />