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ttS tYtt OY tt bit tib tt tttt-tett tt tt IRtt Milk tt tilt tt tit /J <br /> 0: I .S /r ' <br /> t APPLICATI LIR PERMII t: SAN JOAQUIN LOCAL HEALTH 01STi Anee <br /> UNDERGROUND TANK Y 1601 E HAIELTON AVE,, STOCKTON CAt <br /> t CLOSURE OR ABANDONMENT t; Telephone (209) 468-3420 t; <br /> t:n:.x:or n»:..:.t n:n far n:t>:t>:u:na u:n:�x�x u:a:12.":0 0 :n;rx >aa'. <br /> .:•................................ //v������ <br /> APPLICATION FOR PERMANENT/TEMPDRARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTAS STORAGE FACIL7LYG/ <br /> THIS PERMIT EXPIRES 9D DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE P�R J),TYPE BE�L9W: / <br /> XX_ REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE 1 CAC 000171077 , PROJECT CONTACT t TELEPHONE 1 Martin or Richa �T <br /> F FACILITY NAME Sierra Spring Water PNONE <br /> A (800) 221=1100 <br /> C ADDRESS 2477 N. Wig Wan', Stockton, CA <br /> I _ <br /> L CROSS STREET Cherokee V — <br /> 1 <br /> T OWNER/OPERATOR Hard Times Realty PHONE 1 ^' <br /> Y <br /> C CONTRACTOR NAME Jim Thorpe Oil , Inc. `—PHONE 1 (209) 462-4581 _ <br /> N CONTRACTOR ADDRESS 351 N. Beckman Road , CA LIC 1 495699 CLASS A, Haz. <br /> T — <br /> R INSURER SfN7� n1Na1 —' <br /> on file WORK.COMP.I on file �0 f513�-8� <br /> A SU— — ---�^S 1 '�✓ <br /> C FIRE DISTRICT Waterloo/Morada PERMIT VINSPTR <br /> T <br /> 0 LABORATORY NAME PHONE 1 <br /> R on <br /> Environmental _ (209) 983-1340 <br /> SAMPLING FIRMt same SAMPLING METHODBrass tube - See #5 on removal plan <br /> T TANK ID I TANK SIIE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> A 39- / 770 0/ 10,000 _ Unleaded Gasoline <br /> K 39 <br /> N 39- -- <br /> --------------------------- <br /> --------------------------- - --- <br /> 39 ___ <br /> --------------------- <br /> 39 <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P APPROVED __APPROVED WITH CONDITIONS DISAPPROVED <br /> tL ''``` `'' (SEE ACHMENT Wll CONDITIONS) <br /> A PIAM REVIEWERS NAME - Lfi � a <br /> NR----------------DATE__S�a? <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 IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S MIRING OR SUBCONTRACTING S16NATURE CERTIFIES THE <br /> FOLLOWING; '1 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 INSPECT ONS AT LEAST 48 HOURS IN ADVANCE <br /> SI6NE0 Vice-President <br /> -- DATE 5/4/89 <br /> OFFICE DSF (Y--EN 13 016 11/88 ---------------------------------------- --------------------------- <br /> Z <br /> il{fflftffifffffffftfffft{fiffiff{fif4t{ffff{fiffffffiffftftfffifffffff iifftffffffff{fftffftf4ffft{fff{fit{{iftffffft{ff <br /> SWEEPS 1 COMP t LOC 0 DIS- M�-! A O1,1 KCVD CK1/ ASH -RCD Y DATE_ CVO PERMIT t� <br /> G ��z,- <br />