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M tt 111t ILL,Itit ti ttt tt tk'tt tt tttt'tttt It'tt to tttYlttttttLt!'q!t tt'Ct <br /> t: APPLICATIUN FOR PEkAI T r SAN JOAQUIN LOCAL HEALTH DISTRICT e; <br /> a: UNDERGROUND TANK t• 1601 E HAIELION AVE,, STOCKTON CA t: <br /> t CLOSURE OR ABANDONMENT t: ,Telephone (209) 468.3420 t: <br /> a3'tt tft3 t3a't:tt".'tea'l3:3'>a313 43'43'43!:text*t3 433:!3 lxtTr l:!T'IT. <br /> PPLICATIGN IGD? PtPAANENT/TEMPORAP•Y CLOSURE OR ADANOONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> AH15 PCQh1T F.rPIRES 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 /> "I'F ro pe <br /> EPA SITE I CAC 000195488 PROJECT CONTACT i TELEPHONE I 209 46artyarty <br /> 2-4581 <br /> F rmr.ITY NAME Pony Express Courrier PHONE 1 (209) 823-45T2 <br /> C ADDRESS 959 Moffat Blvd. , Manteca, CA <br /> I <br /> L C911i15 STRtET Main Street <br /> I — <br /> T OWNERIOPERAIOR P"y Express Courrier PHONE 1 <br /> 263 S. Maple Street <br /> Y Sn. <br /> - -- -- � _.._.nciss2 ` 89 - _ (415) 952•-3300 <br /> C COMPACTOR *RE Jim Thorpe Oil , Inc. PHONE 1 (209) 462-4581 <br /> 0 ---- <br /> N CONTRACTOR ADPRFSS351 N, Beckman Road, Lodi, CA CA LIC 1 495699 CLASS A, Haz. <br /> R INSURER on file NORK.CCNP.1 on file <br /> A - <br /> C FIRE DISTRICT ' Manteca PERMIT IIINSPIR <br /> Y T --- <br /> 0 LABORATORY NMI Canonie Environmental PHONE 1 (209) 983-1340 <br /> %SAMPLING F10i same SAMPLING METHOD Brass tube-see #5 on removal jTan <br /> TANK 10 s TANK SIIE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOU9T <br /> T <br /> ra9• 000 Unleaded gasoline same <br /> 39. ......... <br /> N ................ <br /> II 39%. <br /> ........................------------------------- <br /> 31- <br /> .......... .........------ <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> r <br /> t APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L I ATTACHMENT ITH CONDITIONS) g <br /> A PLAN REVIEWE►TS HANE --------- = _k <br /> ----------------DATE------ <br /> ........ <br /> - -.._._ <br /> }. N <br /> LV APPLICANT HIST PERtURM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, 00 RULES AMD REGULATIONS <br /> OF tK SAM JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AOfiNT'S SI@NATURE CERTIFIEI-INE I'MIOU1NSt 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE 9022 FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IM IUCN MAl I AS TO V-C <br /> SUNICT 10 WORKERS COMPENSATION LAWS OF CALIFORNIA.' CONTORTOR'S HIRIMB OR SUICONIRACTIIIS SIIINATURE CERTIFIES THE <br /> fOLIOVING,. 'I CERTIFY THAT IN THE PERFORMANCE OF THE UORK FOR IIHICH THIS?UNIT 19 ISSUED, I RNALL EMPLOY rERW MECI <br /> TO WCRKEP'S COPPEHSATION LARS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADYANCEE <br /> .............IA _. Lals9 <br /> .............. <br /> �rr{CE asF mttr--�Ia era ullo- - �.7 . .... <br /> Itiii44flt/tIS}Itiitlt4itlHltlti14191t1it1/1!lilt{liltiitl{/{Itli41i1{litill44i4Ntttilliiibltiili141li1i14ti@Ii1i4111it!{ <br /> SWEEPS I COMP l LOC CODE DIST CODE AMOUNT DUE I AM9lIMI RCVDC /CASH BOB Iry RATE 09 PERMIT 1 <br /> I - <br />