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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 0 CAC 001395520 PROJECT CONTACT 6 TELEPHONE # Gary Wiman (209)333-6800 <br /> F FACILITY NAME Hutchins Street Square PHONE # (209)333-6800 ext 593 <br /> A <br /> C ADDRESS 121 S. Hutchins St. , Lodi, CA. 95240 <br /> 1 <br /> L CROSS STREET Walnut <br /> 1 <br /> T OWNER/OPERATOR The City of Lodi/ Public Works Dept. PHONE # (209)333-6800 <br /> Y <br /> C CONTRACTOR NAME Jim Thorpe Oil, Inc. PHONE it (209)368-6175 <br /> 0 <br /> N CONTRACTOR ADDRESS P.O. Box 357 CA LIC # 495699CLASS A,B,HAZ <br /> T <br /> R INSURER Firemans Fund/Gen StarI WORK.COMP.# <br /> A <br /> C FIRE DISTRICT The City of Lodi I PERMIT #upon approval <br /> T <br /> 0 LABORATORY NAME Krazan and Assoc. COUNTY Stanislaus PHONE # (209)572-2200 <br /> R <br /> SAMPLING FIRM Same as above PHONE # (209)572-2200 <br /> IIIIIIIII11111Iillllllllllllil <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39' Via] ons ��/! t1ui11Cer ol� lllc. <br /> T 39- o>V V V gdl -1F*F�mce't-°2� <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111 I <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) ` <br /> PLAN REVIEWER'S NAME {"'"/G �jY'�'" DATE �/S 6 <br /> 1 1 1 1 1 1 I1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <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: "I 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 CCMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMA,40-6&THE WORK FOR JWNI THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFON ." <br /> APPLICANT'S SIGNATURE: LE Contractor DATE 4/6/98 <br /> CONDITION(S): �, //�6o '�r2ti ihv �jT f3E ST7fiiE GTt�iE� o� PfL-�� <br /> 6orL <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />