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r<kll et tt tt tt R:tt-,tt tit:tt.e;11414t ct tt tt tr&ti:ti: <br /> ''t► t; APPLICATIMOR PERMIT a SAN JOAQUIN LOCAL HEALTH DIT _ <br /> 4< t; UNDERGIM TANK t; 1601 E HAIELTON AVE., STOCK CA <br /> t <br /> CLOSURE OR ABANDONMENT telephone (209) 468-3420 t: p t; <br /> .....� ............................. �t 3 11989 <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT WPLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERM IFft_#(,dkfg7AL HEALTH <br /> c i1 /SERVICES <br /> )L__ REMOVAL _____ TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br /> EPA SITE 1 CAC 000146781 PROJECT CONTACT L TELEPHONE 1 David Chavier (209) 941 1444 <br /> F FACILITY NAME Vacant (Old Butcher Shop) PHONE i <br /> A <br /> C ADDRESS 1210 E. Victor Road, Lodi , CA <br /> L CROSS STREET C 1 of f <br /> I <br /> T OWNER/OPERATOR Bank Of Stockton PHONE 1 (209) 941-1444 <br /> Y P. 0. Box 1110, Stockton, CA 9520 <br /> C CONTRACTOR NAME Jim Thorpe OI1 , Inc. PHONE 1 (209) 462-4581______f <br /> O <br /> N CONTRACTOR ADDRESS 351 N. Beckman Road CA LIC 1 495699 CLASS A, Haz. <br /> T <br /> R INSURER on file WORK.COMP.1 on f i l e <br /> A <br /> C FIRE DISTRICT Lodi PERMIT 1/INSPTR <br /> T <br /> 0 LABORATORY NAME Canonie Environmental PHONE 1 (209) 983-1340 <br /> R <br /> SAMPLING FIRM* O n AMPLING METHOD <br /> T <br /> TANK 10 1 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSL <br /> _ <br /> A 39- e 500 Unleaded Gas Unleaded Gas <br /> N39---------------------------- <br /> K 39- <br /> - <br /> --------------------------- <br /> 39- <br /> --------------------------- <br /> 39- <br /> ----------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P E7APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L (SEE ATTACHMENT WITH CONDITIONS) c/ �j <br /> A PLAN REVIEWERS NAME ----- -=-- -- DATE_��v1�87' <br /> N ------------------------------------- --------------- <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: '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 SUBCONTRACTING SIGNATURE 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 /> CALL F f £�' AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED L.� :t. �-Vice_President DATE 1/31/89 <br /> --- -- .._ x•c--- - - - - --------------------- <br /> --------------------------- <br /> OFFICE E --EN 13 0/6 8 <br /> ffff ffffft fffffifffffff fffffffffitft tfftffftfffffffffffifffftiffffffffffftfftffiftfftfftffffffffffftfftfffftffff <br /> SW PS 1 C 1 LOC CODtDIST CODE OUNT DUE AMOUNT R�yp CKIASH RCVD BY DAZE RCUD PER 1 <br /> r �„ / ( � <br />