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..i <br /> 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 # CAC 000 68648 PROJECT CONTACT d TELEPHONE #Richard Thorpe (209)368-6175 <br /> F FACILITY NAME ZO a 0. Br ner PHONE # N/A <br /> A <br /> C ADDRESS 64 E.Hazelton St. , Stockton CA 95203 <br /> 1 <br /> L CROSS STREET Stanislaus St. <br /> 1 <br /> T OWNER/OPERATOR PHONE # N/A <br /> Y Zoya 0. Bryner <br /> C CONTRACTOR NAME Jim Thorpe Oil, Inc. PHONE # (209)368-6175 <br /> 0 <br /> N CONTRACTOR ADDRESS P.O. Box 357, Lodi, CA 95241-0357j CA LIC 0495699 CLASS ASB, Haz <br /> I <br /> R INSURER Firemans Fund/Gen Star <br /> WORK.cOMP.#1095135 <br /> A <br /> C FIRE DISTRICT PERMIT # pgn approval <br /> T - The City of St <br /> 0 LABORATORY NAME COUNTY PHONE # (209)572-0900 <br /> R <br /> SAMPLING FIRMGeoAmlytical PHONE # _ <br /> 1111111111 <br /> TANK 711111111111111 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY GATE UST INSTALLED <br /> 39- 1..,-Onn gniinns gngnlina �mltnn�m <br /> T 39- <br /> 1 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> IIIIf1TiT11TiliTll n1TTT <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A X (SEE CONDITIONS BELOW ARD/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAME DATE - <br /> 1I I I I I I I I I I I I I I I I I I I111111111111111111111111111111111 11111111111111111111111111111111111111111111111111111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN 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 SMALL 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 PER FORMA F HE WORK FOR WHICH T IS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFO A." <br /> APPLICANT'S SIGNATURE. <br /> TITLE Contractor DATE) / <br /> CONDITION(S): Contractor will contact USA DIG at least 48 hours prior to any excavation. <br /> yj <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />