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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 /> EPA SITE N 002100064 PROJECT CONTACT S TELEPHONE N Jim Thorpe Oil , Inc. (209) 368-6175 <br /> F FACILITY NAME Van De Pol Enterprises PHONE N (209)466-5921 <br /> A <br /> C ADDRESS <br /> I 3147 S. E1 Dorado St . , Stockton CA 95206 <br /> L CROSS STREET Ivy St . <br /> I <br /> T OWNER/OPERATOR PHONE N <br /> Y Van De Pol Enterprises (209)466-5921 <br /> C CONTRACTOR NAME Jim Thorpe Oil , •Inc. PHONE t (209) 368-6175 <br /> 0 <br /> N CONTRACTOR ADDRESS P, p, Box 357, Lodi , CA 95241 CA LID N 495699 CLASS A, B, Haz. <br /> I <br /> R INSURER �enstar / Kemper NORK.COMP.E 007197-97 <br /> A <br /> C FIRE DISTRICT The City of Stockton PERMIT M upon Approval <br /> T <br /> 0 LABORATORY NAME GeoAnalytical Labs COUNTY San Joaquin PHONE N (209) 572-0900 <br /> R <br /> SAMPLING <br /> i1RM 1 ical Laboratories PHONE N (209) 572-0900 <br /> TANnIInIInInIII���t9�Vi�ll��l [�1l�gz S p� <br /> 79• (K 1' IUH Ve <br /> gallons CHEMICALS15e%CUBRE6,LLS/Ol1fOUSLY DATE UET INSTALLED <br /> ne <br /> T 39. 10 ,000 gallons UUUnllea e Gasoline Uk <br /> A 39- <br /> 10,0N 39• nn gallons lliQ�el Fuel 3i1r <br /> K 79- <br /> 39- <br /> 39- <br /> P IIIITTTTTTTTTiiTlilliTTTlTllil TTTTTTIITiiTTTiTTTiTliTT1TTITTTT iTT1T <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A J EEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S <br /> N //) iUiT.(.EiJ s DATE 'Y7�'O.r ?/ <br /> NAME_ Q ? l�J' <br /> — IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIITTIIIIITITTTTIITTTTTTITTT��I�TTTTTT���I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINGS •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 FOLLOWINGS <br /> "I CERTIFY THAT IN THE PERFORMANCE OF WORK FOR WHICH THIS P NIT 1S ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> I <br /> APPLICANT'S SIGNATURES LE Contractor/Agent DATE 8/19/98 <br /> COND ON(S)1 <br /> i�DYL1 ate- az�� <br /> IN 23 046 (REVIEW 9/11/90 pEyB 3 <br />