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f' nrrLi4nIIUri ruK rtrnfd t: SAR JUAWWR MAL MEAL.111 ul <br /> UNDERGRO TANK 1601 E HAIELTON AVE., STo- r. <br /> t: CLOS DONMENI t: Telephone (209) 468K A6. <br /> i iZ'tZ iZ iZ' iZ i',tZ iZ iZZ::'i:iZ:ir:.Z:►.;iZ'i'.iZ i.3Z i;:►;lZ:iriZ:ffYirtx <br /> APPLICATION FOP PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> 1919 PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DD NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOWS <br /> _ REMOVAL _ TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> __— EPA SITE <br /> TE I CRC 000294697 �- ----_-_- - PROJECT CONTACT I TELEPHONE Larry Aks1and-----� - <br /> ----- TNG---___.-.. 209) 823-7124 <br /> F FACILITY NAME Larry Askland, Inc. PHONE # (209) 823-7124 <br /> C ADDRESS 8282 Veritas Ave. , Manteca, CA 95336 <br /> L CROSS STREET S. Main <br /> w <br /> T OWIIER/OPERATOR same as above PHONE I same <br /> Y <br /> C CONTRACTOR NAME same as above - Owner PHONE 1 <br /> N CONTRACTOR ADDRESS CA LIC 1 385491CLASS:B/C 12 <br /> R INSURER Home Insurance #GLRF 386240 WOP,K.COMP.1 <br /> 4 Comp WP 90494459-- 01 <br /> A - .- <br /> C FIRE DISTRICT PERMIT IIIMSPTR d <br /> Manteca/Lathrop <br /> T — _,. <br /> 0 LABORATORY NAME FGL Environmental or PHONE 1 (209) 942-0181 <br /> P Canonie Environmental _— (20 ) 983-1340 <br /> SAMPLING FIRMv SAMPLING METHOD brass tube-see #5 on removal p an <br /> TANK ID I TANK SIZE ? CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> T <br /> A T1_ 800 t'� ` Leaded Reg. gasol-- ne same <br /> N 19- <br /> 39- ------------ <br /> ----------------------- <br /> — <br /> J4-------------------- i <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> r <br /> P __ APPROVED APPROVED WITH CONDITIONS --' DISAPPROVED <br /> L (SEE AIIACHMENT WITH CONDITIONS) <br /> A PIAN REVIEWERS NAME <br /> N ---- DATE <br /> -----�----------------------------- .... <br /> ----_----------- <br /> 11111-11-is I milli=0111111111 I NOR IN" I <br /> APPLICANT RUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAM JOAAUIR LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 41 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHIC9 THIS PERMII IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> SUAJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRIHR OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING, 91 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br /> 10 WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR NSPECTIONS T LEAST 48 HOURS IN ADVANCE <br /> SIGNED- - - =-=--=----- -- -- - - ------- DATE ---------------. <br /> OFFICE off (1'--Ell IJ 0t !1108 <br /> SWEEPS 1 COMP 1 1 LOC CODE JOIST CODE AMOUNT DUE I AMOUNT RCVD CKI/CASH RCVD BY DATE 900 PERMIT 1 <br />