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tit tt it-it,ttt R it ttt it k411-41 t4Ut;:tt at:tl t:tt:tt twtitb HF <br /> - <br /> c APPLICATI3OR PERMIT F SAN JOAQUIN LOCAL HEALTH DI T 4 <br /> t UNDERGROUND TANK t; 1601 E HAZELTON AVE,, STOCKTON C46 <br /> t: CLOSURE OR ABANDONMENT t Tel phone (209) 468-3420 <br /> K;�C;�:x:;�:?:.:�:>�:::Sa:.sa:u:.a:.x Vis:ta:u'n:�x nt;�aa:n:►x►x aa:ra:►.�:ix►x�x�>:Via: <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> x_ REMOVAL ----- TEMPORARY CLOSURE ABANDONMENT IN PLACE l 'Al <br /> FEPA SITE I CAC 000151965 _ I PROJECTCONTACTi TELEPHONE 1 <br /> FACILITY NAME NAKATA NURSERY PHONE 1 (209) 823-5407 <br /> C ADDRESS 1271 North Main Street, Manteca, CA <br /> I <br /> LCROSS STREET <br /> I Louise Avenue <br /> T OWNER/OPERATOR PHONE 1 — <br /> Y <br /> C CONTRACTOR NAME JIM THORPE OIL, INC. PHONE 1 (209) 462-4581 <br /> 0 _ <br /> N CONTRACTOR ADDRESS 351 N. Beckman Road CA LIC 1 495699 CLASS A, Haz <br /> T <br /> R INSURER on file WORK.COMP.t <br /> A _ on file <br /> C FIRE DISTRICT Manteca City PERMIT I/INSPT <br /> T <br /> 0 LABORATORY NAME Canonie Environmental PHONE 1 (209) 983-1340 <br /> R <br /> SAMPLING FIRM} P 0 j,3/ a SAMPLING METHOD <br /> �2-ass b <br /> TANK 10 1 TANK SIZE CHEMICALS STORED CURRENTL CHEMICALS STORED PREVIOUSL <br /> i <br /> A 39-____�9(0�o -D / 500 al . Req. Gas Reg . Gas <br /> N34- ----------------- -- _ <br /> --------------------------- -- <br /> K 39- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L * T (SEE ATTACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME -___________ /iyJ ._ ✓_/_(-C�____ DATE­ <br /> - <br /> ATE �_ <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 DR 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 HAMMER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING S16NATURE CERTIFIES THE <br /> FOLLOWIWG: 11 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL ENPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INS CTI S AT LEA V 48 HOURS IN ADVANCE <br /> SIGNED <br /> - -- - -- -=�--- --- -== ----�....................DATE <br /> l�$ <br /> ---------- - - -- - <br /> OFF1Cf DSf OM(1-- OI 11/I9""'-__"'"-'"--- <br /> f{f{{{{{f{{{f{{ ffiff{ ffffff {f{fff{fffiffffif{{ff fiffff{{ft{{ffff{{i{{{{f{if{{f{{{iffff{fff{ffif{fffftfffffiff{ <br /> SWEEPS 1 COMP LOC ODE IDIS;TCODE AM T DUE AMOUNT RCVD CKI/CASH RCVD BY I OAT KCVO PERMIT 1 <br /> O ��sG�� <br />