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l <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> 111E PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERONCILMO MALIRDOUf SUBSTANCE ITOIUW TANK <br /> EXPIRES 90 DAYS FROM INE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREA$. INDICATE PERMIT TYPI IELOWI <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE rCAL 000049384 PROJECT CORTACI S TELEPHONE / Jim Thorpe Oil , Inc. (209) 368-6176 <br /> F FACILITY xAH! Lincoln Unified School Dist. Maintainence Yard PNoxE / 2 <br /> 09)95 -8595 <br /> C <br /> ADDRESS 6749 Harrisbur Place Stockton CA 95207 <br /> I <br /> L CROSS STREET Benjamin Holt Dr. <br /> T OWNER/OPERATOR PHONE I <br /> Y Lincoln Unified School District (209)953-8700 <br /> C CONTRACTOR NAME Jim Thorpe oil , -Inc. PHONE / (209) 368-6175 <br /> N CONTRACTOR ADDRESS p 0. BOX 357, Lodi , CA 95241 CA LIC R 495699 <br /> 1 CLAEE A, B. Naz. <br /> R INSURER Firemans Fund/Genstar WORK,CoMP,/ 007197x97 <br /> A <br /> C FIRE DISTRICT The City of Stockton PERMIT / upon apnro,�7al <br /> I <br /> R LANORAtORY NAMEGeoAnalytical Labs COUNTY San Joaquin PHONE r (209) 572-0900 <br /> SAMPLING FIRM 1 cal Laboratories PHONE r (209) 572=0900 <br /> - nnnuu��G�I����i9�IlPu�ll <br /> �1 NK fl1E CHEMICALSf STORE CYR TLY/PREVIdJSLT DA1!! Ulf INSTALLED <br /> 39- 2 --O / _ l0,Od8al.lons tliese4 fuel uk <br /> T 39' - 10.000eallon� diesel fuel „k <br /> A 39%N 39- ?A l)QLLga]loTls gasolino y}4 <br /> K 39-- <br /> 39- <br /> P <br /> 9- <br /> 39- <br /> nllnmm�mnrfull IIIIIr [if rmMIIMulti rrlmiIIII rrr mmmnmrrrmr <br /> L _ APPROVED t APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACMMENI) <br /> N <br /> PLAN REVIEWER'S NAME w. JL DATE <br /> - Illllllllllllllllllllilllllllllllllllllllllllllllllllilllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAMS, AND RULES AND REGULATIONS Of <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TNS FOLLOWINGI "1 CERTIFY THAT IN <br /> TNF PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A$ TO SICOW <br /> SUBJECT TO WORKER'S COMPENSATION LAWS Of CALIFORNIA." CONTRACTOR'S HIRING 00 SUICONtRACTINO 11ONATURI CERTI►IE/ 101 ►OLLOWINGR <br /> "I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH IN PERMIT 19 ISSUED, I SNALL EMPLOY PERSONS IUIJECf t0 WORKER,# <br /> COMPENSATION LAWS 0► CALIFOMNI r' - <br /> I <br /> APPLICANT19 SIGNATUREI TLE Contractor/Agent oATt 7/21/98 <br /> COND nw(S)I —S <br /> C�rnw,Oti,u� c�rWu— . <br /> EE 23 046 (Rdolod 9/11/96) Page 3 <br />