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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL _ TEMPORARY CLOSURE _ ABANDONMENT IN PLACE <br /> EPA SITE M CAC000647448 PROJECT CONTACT i TELEPHONE M <br /> Richard Thor e (202)368-6175 <br /> F FACILITY NAME Dole Fresh Frtiit Co. PHONE k <br /> A (209)334-2780 <br /> C ADDRESS 8751 E. Hwy 12 Victor, Ca.95253 <br /> I <br /> L CROSS STREET Bruella Rd. <br /> I <br /> I OWNER/OPERATOR Same as above PHONE M <br /> Y <br /> C CONTRACTOR NAME ,Jim thorpe 011 Inc./DBA Rich-Mart PHONE M <br /> 0 (209) 368-6175 <br /> N CONTRACTOR ADDRESS 351 N Beckman Rd.Lodi, Ca. CA LIC 0 4 CLASS <br /> r 95699 A,B Haz. <br /> R INSURER FameX/ Admiral <br /> A VORK.CONP.M 0n file <br /> C FIRE DISTRICT Victor PERMIT M J.re perms wl e <br /> T obtained upon approv. <br /> 0 LABORATORY NAME F.G.L. Environmental PHONE M <br /> R (209) 942-0181 <br /> SAMPLING FIRM Same as above PHONE M <br /> Same as above <br /> TANK ID M TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 550 gal. U1 Gasoline p <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P IIIIIIIIIIIIIIIIIIIIIIIIIII"' IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIII ' <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> I I111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I' <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 (ARK 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 FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: JL�TITLE DAZE <br /> Contractor 10/21/91 <br /> EH 23 046 (Rev 2/8/91) It - --� I; G Page 3 <br />