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SAN ..AQUIN COUNTY PUBLIC HEALT! ERVICES <br /> ENVIRONMENTAL HEALTH DIVIST6N <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. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> IR REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPASITEtCAC% 002568804 1 PROJECTCONTACT Ed Wahl PHONE# (209)937-8358 <br /> FACILITYNAME The City of Stockton Property PHONE#N/A <br /> ADDRESS 428E. Fremont St . , Stockton, CA 95202 <br /> CROSS STREET Sutter St . <br /> OWNER OPERATOR PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Jim Thorpe Oil, Inc. PHONE#CZO9)36B-6175 <br /> CONTRACTOR ADDRESS P.O. Box 357 CALIC# 495699 CLASS ABHaz <br /> INSURER Firemans Fund WORKERCOMP# 1671173 <br /> FIREDISTRICT e City of Stockton PERMIT# upon approval <br /> LABORATORY NAME COUNTY PHONE# <br /> SAMPLING FIRM PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- 05-101 500? Heating Oil Diesel Unknown <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATIPN LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: "I CERTIFY THAT IN T RF CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF AL <br /> APPLICANT'S SIGNATURE TITLE Contractor DATE8/12/03 <br /> ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> T (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME r DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046(REVISED 08/13/99) Page 3 <br />