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W fftktt it NN 1:01-tatftl4k1:1tt 011er'tutfitaltitt�titatat►�eu <br />f APPLICATION RMIi f SAN JOAQUIN LQCAL HEALTH OISTR <br />f UNDERGROUNDNDTANK f 1601 E MATEITBM AVE., STOCKTWI CAf <br />t CLOSURE OR ABANDONMENT f Telephone (209) 468-3420 f <br />:. tt..J. t` ...... ;xn:Ixgtu::Y:: t:: n: tr.lan:Lrn. <br />JULY 2 71989 <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STO AGE FACILITY <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERN'lPTIFfUlEtIlet HEALTH <br />PERMIT / SERVICES <br />XX REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br />---- ----- ---- to <br />an <br />a <br />EPA SITE 1 <br />PROJECT CONTACT Y TELEPHONE 1 Ri h or Marty Thorpe <br />CAC 000194948 <br />(?09) 462=4587 <br />F <br />FACILITY NAME Formerly: Lodi Lumber <br />PHONE ► <br />C <br />ADDRESS 1025 Industrial Way, Lodi, CA <br />L <br />I <br />CROSS STREET S. Beckman Road <br />T <br />OWNER/OPERATOR Industrial Way Developers <br />— <br />PHONE 1 (209) 465-5883 <br />Y <br />C <br />Tm Thorpe Oi 1 ,® .+ — <br />CONTRACTOR NAME p <br />PHONE 1 (209) 462-4581 <br />N <br />CONTRACTOR ADDRESS 351 N. Beckman Road, Lodi, CA <br />CA LIC 1495699 <br />CLASS A, Haz. <br />T <br />R <br />INSURER on file <br />WORK. COMP. I on file <br />C <br />FIRE DISTRICT pdj <br />PERMIT I/INSPTR <br />-- <br />T <br />0 <br />LABORATORY NAME,tlanonie Environmental <br />PHONE 1 (209) 983-1340 <br />SAMPLING FIRM, same SAMPLING METHOD Brass tube -see #5 on removal p <br />TANK ID I TANK SITE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSL <br />T <br />A <br />/ I aS — <br />31%.1. -- -'-'- --- --- <br />N <br />39- ._.%�3- - 500 <br />K <br />39- <br />9-39- ----- <br />31 -------------------- <br />31--------------------------- — -- <br />LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br />APPROVED APPROVED WITH CONDITIONS _--_ DISAPPROVED <br />lLkw <br />(SEE ATTACHMENT WITH CONDITIONS) <br />/ <br />PLAN REVIEWERS NAME _I ---v---- - <br />`T <br />111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <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 15 ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br />CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br />✓/ 'Z,b.Q <br />SIGNED ---------- VicecPCg�?_4gAt---------------- DATE --- Zlwe.UM-------------- <br />OFFICE OSE ONIr--Eg 23 016 1218E 7� <br />{{{ftt{f/{f4f{{tfftftfffftffff{tfffftf{ffffftf{fffi{4fffftfffftffffffffffffflffffffftffffiftlffffffftffifttffftf{ififffft <br />SWEEPS 1 I COMP 1 BLOC CODE DISC T CODES AMOUNT DUE I AMOUNT RCVD I CKf/CASH `RCVD BY DATE RCVD PERMIT f <br />an <br />a <br />