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UNDER '0 TANK r 1bv1 L nnlulUn n,c.j �. <br /> CLOSURE _. ARANDONMENT Telephone (209) 468-3,.. f: <br /> �. ...................01.1..x...... <br /> APPLICATION FOP. PERMANENTIIEMPORAP,Y CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EIPIRES 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 <br /> PROJECT CONTACT W TELEPHONE 1 arty or i—R c orpo <br /> EPA SITE 1 CAC 000272441 (209) 462-4581 <br /> F FACILITY NAME Charles E. Skobrak PHONE 1 (209) 465-2667 <br /> A <br /> C ADDRESS Mn r Avenue, Stockton, CA <br /> I <br /> L CROSS STREET Grant Street <br /> I <br /> T OWAERIOPERATOR Charles E. Skobrak PHONE 1 (209) 465-2667 <br /> Y <br /> C CONTRACTOR NAME Jim Thorpe Oil , Inc. PHONE 1 (209) 462-4581 or 368-6175 <br /> O -- <br /> N CONTRACTOR ADDRESS 351 N. Beckman Road, LodigU40 CA LIC 1 495699 CLASS A, Haz. <br /> T �— <br /> R INSURER on file WORK.COMP.1 on file <br /> A --'_--------- --------�--- — <br /> C FIRE DISTRICT City of Stockton PERMIT IIINSPTR <br /> 0 LABORATORY NAME Canonie Environmental PHONE 1 (209) 983-1340 <br /> P. <br /> SAMPLING FIRM# same SAMPLING METHOD brass tube-see #5 on removal p an <br /> TANK 10 1 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSL <br /> T <br /> A 39- X80— /C200 Regular gas <br /> Te—se, <br /> K79----------------------------- <br /> 79 <br /> --------------------------- <br /> 39- <br /> --------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P ____ APPROVED )C APPROVED WITH CONDITIONS __ _ DISAPPROVED <br /> L (SEE ATIACNM ii WITN CONDITIONS) <br /> A PLAN REVIEWERS NAME ----------------- --- -----------DA1E.....,� �6 'lC)--------- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAM 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: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, 1 SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL LLr <br /> TI S AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED / DATE April 19 , 1990 <br /> -------------------------- <br /> OFFICE U ntSSSSWEEPS 1 COM CODE AMC DUE I AMOUNT RCVD I CKI/CASH I RCVD BY I DATE RCVD I PERMIT 1 <br />