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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 BELOVI <br /> X REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE R GAC 000898968 PROJECT CONTACT It TELEPHONE R Richard Thorpe (209)368-6175 <br /> F FACILITY NAME Donald Colvin PNONE R ( (510)682-0392 <br /> A — <br /> C ADDRESS 225 S. Cresent Ave. Lodi, Ca 95240 <br /> I <br /> L CROSS STREET Lodi Ave. <br /> I <br /> I OWNER/OPERATOR PHONE R <br /> Y Donald Colvin (510)682-0392 <br /> C CONTRACTOR NAME Jim 'Thorpe 011 , IIIc. PHONE R (209)462-4581 <br /> 0 <br /> N CONTRACTOR ADDREs9351 N Beckman Rd. P-O.BX. 357 CA LIC R 4 r6 CUSS <br /> i11 T <br /> R INSURER Piresmans Fund/ Pacific Insur. Co. , LTD WORK.COHP.R a e , ns. u d <br /> A r <br /> C FIRE DISTRICT City of Lodi PERMIT ROIL approval <br /> I <br /> 0 LABORATORY NAME GeoAnal tical PHONE 0(2D 572-0900 <br /> R <br /> SAMPI.INC, TIPH Same as above PHONE R ,game as above <br /> I I I 1111111 <br /> TANK 111111111111111 <br /> TANK IDR TANK 512E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- Approx 280 gallons Gasoline Unknown <br /> 1 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> PI. nnnnrnnnrrrnnnmm mnrrrrnnrnrrrrrrnrrmnr mnmm�rrrrnnrtrttnmrmmrr rrrrrrrmrnrrrmrr <br /> N PIAN REVIEWERS MANE G APPROVED� E APPROVED WIT" H CONDITIONS DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> 1111111111111 11111111111111111n <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIM COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN 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 F THE WORK FOR CN THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." --�-�- <br /> APPLICANT'S SIGNATURE:.�'� i Lc..- �J <br /> TITLE ContraCLor DATE 2/7/94 <br /> EH 23 01.6 (Revised 7/10/92) Page 3 <br />