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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <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 _ CLOSURE IN PLACE <br /> EPA SITE M CAC 000896616 1 PROJECT CONTACT i TELEPHONE B Martin Thorpe (209) 368-6175 <br /> F FACILITY NAME JOLLY JOE'S BAIT & TACKLE PHONE K 209 948-6344 <br /> A <br /> C ADDRESS 101 W. Charter Way, Stockton, CA <br /> I <br /> L CROSS STREET Commerce St. <br /> I PHONE X <br /> T OWNER/OPERATOR <br /> Y Ron Shelan (209) 948-6344 <br /> C CONTRACTOR NAME Jim Thorpe Oil, Inc. PHONE Y (209)462-4581 <br /> 0 <br /> N CONTRACTOR ADDRESS351 N Beckman Rd. P.O.Bx. 357 G LIC w 4 56 CUSS A.13 <br /> I WORK.COMP.M <br /> R INSURER Firesmans Fund/ Pacific Insur Co— TD1099135 <br /> A PERMIT Y <br /> C FIRE DISTRICT City of Stockton On approval of plan <br /> T <br /> 0 LABORATORY NAME Geo Analytical PHONE M <br /> R <br /> SAMPLING FIRM ryeQ Ana ytical ,i PHONE k <br /> 111111111111 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TAN <br /> 39- L Waste Oil Unknown <br /> — �5f1 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> P <br /> L APPRO D PROVED WITH CONDITION(S) <br /> DISAPPROVED <br /> A TACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 11111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK. FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE Contractor DATE 11/10/93 <br /> hr <br /> EH 23 046 (Revised 7/10/92) / Page 3 P1 <br />