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9:11111 1 ttt3 tit 1111 tt tt-'t1 till-t1 ti t1 tt tt ti tt tt t1't ti txC>:•y <br /> 1: APPLICAT! : PERMIT r SAN JOAQUIN LOCAL HEALTH 01' <br /> UNDERG—.,,u TANK C 1601 E HAZELTON AVE., STOCK... CA t: <br /> 1: CLOSURE OR ABANDONMENT 1: Telephone (209) 468-3420 t: <br /> n:�):uc n:�r u:n:►r,u:Na 1�J_�):�x�>:u:►J:q: >:►]i�>�X:Y.W,►:::::PY q:Io.►):by.by.b): <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. 00 NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br /> _X_ REMOVAL TEMPORARY CLOSURE __-_ ABANDONMENT IN PLACE <br /> EPA SITE 1 CAC 000186463 PROJECT CONTACT & TELEPHONE 1 Martin Thorpe <br /> (209) 462-4581 _ <br /> F FACILITY NAME KBTS PHONE a (209) 823-3897 <br /> A <br /> C ADDRESS 9901 Woodward Road, Ripon, CA <br /> I <br /> L CROSS STREET Moffat Road <br /> 1 <br /> T OWNER/OPERATOR KBTS PHONE 1 (209) 823-3897 <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.1 on file <br /> A <br /> C FIRE DISTRICT" L/-a <br /> Tp n / >iLe PERMIT 1/INSPTR <br /> 0 LAIORATORY NAME Canonie Environmental (209) 983-1340 <br /> R <br /> SAMPLING FIRM} same SAMPLING METHOD See K5 on tank removal plan <br /> TANK 1D 1 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSL <br /> A 39- /CCC O/ 300 to 500 Waste Oil <br /> ----_ 300 to 500 Waste Oil <br /> K !- <br /> 31 <br /> --------------------------- <br /> 39- ______________________ <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P __-- APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L (SEE ATTACHMENT WITH CONDITIONS) <br /> A KM REVIEWERS NAME DATE <br /> AM ICANi 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 S16MATURE CERTIFIES THE FOLLOWING. '1 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 /> SUIJECT 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 ISSUER, 1 SHALL EMPLOY PERSONS SUBJEC <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL F LEAST 48 HOURS IN ADVANCE <br /> SIGNED _ _ Vice-President ------DATE 6/20/89 <br /> OFFICE E lr -EM 13 46 f? -'-- - - - --------------------- --------------------------- <br /> lsss iss is fsfss{fsSsflffissss�fifffsffsfis fssffflisssislfs11s1sfssisfsfssfssississsissfsfstsfssifsss{fstfssssfffs <br /> 1 I C 1 LOC CODE DIST CODE AM DUE I AMOUNT RCVD I CK1/CASH RCVD BY I DATE RCVD I PERMIT 1 <br />