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i <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 PUCE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK I <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 /> EPA SITE # GAC 00 1166584 1 PROJECT CONTACT R TELEPHONE #Kelly Thnrpp <br /> - <br /> F FACILITY MAKE Tri Star Homes, LLC PHONE 0(510)838-1460 <br /> A <br /> C ADDRESS 1325 N. Corral Hallow Rd. , Tracy CA <br /> I <br /> L CROSS STREET Grant Line Rd. <br /> 1 <br /> T OWNER/OPERATOR Tri Star Homes PHONE # (510)838-1460 <br /> Y <br /> C CONTRACTOR NAMEJim Thorpe Oil, Inc. PHONE #(209)368-6175 <br /> 0 <br /> N CONTRACTOR ADDRESS 351 N. Beckman Rd./P.O. Bx 357 cA Llc # 495699 CLASS''A,B,HAZ <br /> T <br /> R INSURER Firemans Fund/General Star WORK.COMP.# 1095135 <br /> A <br /> C FIRE DISTRICT The City of Tracy PERMIT # upon approval <br /> T <br /> 0 LABORATORY NAME GeoAnaylytical COUNTY San Joaquin PHONE # (209)572-0900 <br /> R <br /> SAMPLING FIRM GeoAnalytical Laboratories PHONE # (209)572-0900 <br /> 1111111111 <br /> TANK [11111111111111 <br /> TANK l0 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 300 gallons ld kasoline uk <br /> T 39- A00 gn I l ang T r( gasoT;nc Ilk <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111111111111111111111111 (111171iTTiTliflfiTTT <br /> L _ APPROVED A APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N o 9 <br /> PLAN REVIEWER'S NAME I � DATE S'2LJ <br /> 1111111111111111111111111 II 111111 I 1 IIIIIillllllllllllltlllliilllllllllllllllllliiilllllllllllillllllllllllilillll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAGUIN 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 /> "1 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 /> Contractor <br /> APPLICANT'S SIGNATURE: - e. tA— TITLE DATE 5/19/97 <br /> CONDITION(S): <br /> EH 23 046 (Revised 9/71/96) Page 3 �i <br />