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e�J <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />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 />CONDITION(S), A «vSo-,eC L.E77.>,- C-9,( / Ssu'So .q Cv,C4�6117— <br />/h� <br />EN 23 046 (Revised 9/11/96) Page 3 <br />EPA SITE # CAC ool463568 <br />PROJECT CONTACT i TELEPHONE # Jim Thorpe OU , Inc. (209) 368-6175 <br />F <br />FACILITY NAME Henry Hansen Property <br />PHONE # <br />A <br />C <br />I <br />ADDRESS200 S. Cherokee Lane Lodi CA 95240 <br />L <br />I <br />CROSS STREET Lodi Ave. <br />T <br />Y <br />OWNER/OPERATOR <br />Henry Hansen c/o Right Way, Inc. <br />PHONE # <br />(209)369-7335 <br />C <br />0 <br />CONTRACTOR NAME Jim Thorpe Oil, -Inc. <br />PHONE # (209) 368-6175 <br />N <br />CONTRACTOR ADDRESS p. 0. Box 357, Lodi CA 95241 <br />CA LIC # 495699 <br />CLASS A, B, Haz. <br />I <br />, <br />R <br />INSURER Firemans Fund/GenstarWORK.COMP.# <br />007197-97 <br />A <br />C <br />FIRE DISTRICT <br />PERMIT # Upon approval <br />MEGeoAnal•ytical Labs <br />COUNTY San Joaquin <br />PHONE # (209) 572-0900 <br />l 1Ca1 Laboratories PHONE # (209) 572-0900 <br />ID �Irf l <br />ID TANK 512E CHEMICALS STO ED U ENTLY/PREVIOUSLY D UST INSTALLED <br />�$tK <br />r39 <br />z 350 wase�ig <br />- <br />N <br />39- <br />39- <br />39- <br />P 1111111111111111111111111 (TffjT <br />L APPROVED K APPROVED WITH CONDITION($) DISAPPROVED <br />A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N 9 <br />PLAN REVIEWER'S NAME j�F`/Li � I!,[«'r'r+DATE <br />I I111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <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: "i CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 />COI CERTIFY THAT IN THE PERFOIIMAN WON �WNICM T IS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />-ENSATION <br />LAWS OF CALIFORNI ." \ <br />APPLICANT'S SIGNATURET Contractor/Agent DATE 6/16/98 <br />CONDITION(S), A «vSo-,eC L.E77.>,- C-9,( / Ssu'So .q Cv,C4�6117— <br />/h� <br />EN 23 046 (Revised 9/11/96) Page 3 <br />