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SAN JOA WIN COUNTY PUBLIC HEALTH F RVICES <br />er4VIRONMENTAL HEALTH DIVISI(.,,W <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NCT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />® REMOVAL <br />❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />TANK INFORMATION <br />FACILITY INFORMATION <br />CONTRACTOR NAME <br />EPAS17EICAC001381617i <br />FACILITY NAME <br />PRO.:ECTCONTACT Lavor Thompson <br />O- 1 e <br />I PHCNEO(209)369-4751 <br />I PHONE K 209 369-4751 <br />ADDRESS <br />310 N. Cluff Ave. Lodi. CA 95240 <br />enStar <br />CROSS STREET <br />Lockeford St. <br />City of Lodi <br />OWNER OPERATOR Lavor Thompson <br />I PHCNE# (209)369-4751 <br />TANK INFORMATION <br />CONTRACTOR INFORMATION <br />CONTRACTOR NAME <br />j im 1norpe Oil, <br />Inc. I PHONE* (209)368-6175 <br />CONTRACTOR ADDRESS O?C C <br />ICA LIC# 495699 1 CLASSA $.HAZ <br />INSURER emper <br />enStar <br />1 WORKERCOMP# 1095135 <br />FIREDISTRICT The <br />City of Lodi <br />1 PERMIT# upon approval <br />LABORATORYNAME <br />GeoAnalytical <br />LaboratoriE:'9UNTY Stan I PHONE# (209)572-0900 <br />SAMPLING FIRM <br />GeoAnal tical <br />LaboratorileVONE # (209)572-0900 <br />TANK INFORMATION <br />TANK IDt <br />I TANK SIZE I TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />39- <br />500 eal.1 diesel fuel uk <br />39- <br />39- <br />39- <br />39- <br />39- <br />APPUCANT MUST PERFORM ALL WORK IN ACOORDANCE WITH SAN JOACUIN COUNTY ORDINANCES. SATE LAWS, FEDERAL LAWS. AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR UCENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING. -1 <br />CERTIFY THAT IN THE PERFORMANCE OF THE'NORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NCT EMPLOY ANY PERSON IN SUCH A MANNER AS <br />TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CON TRACTOR'S MIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: 'I CERTIFY THAT IN � TH��.y'ERFCRMANCE OF THE RK FCR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OyAk$JORNIA.' �]i�/ <br />APPLICANTS SIGNATURE <br />Contractor DATE 12/20/98 <br />[�,APFROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />p (SEE CONDITICNS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME ` /"'_✓ DATE % Ll / <br />r <br />ANY DEVIATIONS FROM THIS APPL1CATiON MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />Er. 23 046 REVISED 10/19/98) Page 3 <br />