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SAN J%. „QUIN COUNTY PUBLIC HEALTH._.ERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE. <br /> CE REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE 9CAL00003,5904 1 PROJECT CONTACT Martin Harris I PHCNE* - <br /> FACILITYNAME Tuff Boy Trailers I PHCNE,.,4209)239-13U1- <br /> ADCREss 5151 Almondwood, Manteca, CA 95337 <br /> CROSS STREET Air Port Way <br /> OWNEROPERATCR j'ujj Boy Leasing, Inc . I PHONE - <br /> CONTRACTOR INFORMATION <br /> CCNTRACTCRNAME Jim Thorpe Oil , Inc . I PHONE* (209 )368-6175 <br /> CONTRACTOR ADDRESS ox 3o7 CA LIC* 495699 CLASSA $ HAZ <br /> INSURER e per enJ ar WORKER CCMP* 1095135 <br /> FIREDISTRICT San Joaquin Uounty I PERMIT* upon approval <br /> LABORATORY NAME Gen An a 1 yt i na I T,nhs I COUNTY Stq n I PHONE <br /> SAMPLING FIRM gfjI PHONE <br /> TANK INFORMATION <br /> TANK ID* ( TANK SIZE TANK CONTENTS(PRESENT 3 PAST) DATE INSTALLED <br /> 39- 44,-2- y—p 1100 gals. unleaded gas I unknown by Cont . <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. SATE LAWS, FEDERAL LAWS,AND RULES AND <br /> PEGULATIONS OF SAN JOACUIN COUNTY PL'BUC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FCLLCWING. 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NCT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WCRKER'S COMPENSATICN LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLCWING. 'I CERTIFY THAT IN ERFOR E OF HE,VCRK FCR WHICH THIS PERMIT iS ISSUED,I SHALL EMPLOY PERSCNS SUB:EOT TO <br /> WORKER'S COMPENSATION LAWS F C FORN <br /> APPLICANTS SIGNATUR;t:- 'ITLE Contractor DA7E12/17/98 <br /> ❑ APPROVED QkAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (�S /CCNCIIT,.CNS BELOWAND/CR CN A,,ACHMENT) <br /> PLAN REVIEWER'S NAME <br /> ANY DEVIATIONS FROM TH APPUCATiCN MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> I <br /> I <br /> Er 22 046(REVISED 10/19/98) Page 3 <br />