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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERNfIT <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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # CAL 000041551 PROJECT CONTACT i TELEPHONE # Jim Thorpe 071 , Inc ( 209) 368-6175 <br />F FACILITY NAME The Port of Stockton PHONE #(209)946-0246 <br />A <br />C ADDRESS 2201 W. Washington St./P.0. Box 2089, Stockton, CA 95201-2089 <br />1 <br />L CROSS STREET Nagy Dr. <br />T OWNER/OPERATOR Same as above PHONE # <br />Y (209)946-0246 <br />C CONTRACTOR NAME Jim Thorpe Oil , -Inc. PHONE # ( 209) 368-6175 <br />0 <br />N CONTRACTOR ADDRESS p. 0. Box 357, Lodi , CA 95241 CA LIC # 495699CLASS A, B, Haz, <br />T <br />R INSURER Firemans Fund/Genstar WoRK.cOMP.# 007197-97 <br />A <br />C FIRE DISTRICT The City of Stockton PERMIT # upon approval <br />T <br />0 LABORATORY NAME GeoAnalytical Labs COUNTY San Joaquin PHONE # (209) 572-0900 <br />TII <br />AMPLING FIRM 1 ical Laboratories <br />lltIIIIIIItlltl 0,61l <br />TAN ID # TAIIi�K S I ZE <br />39- 2 Z - . _ 1210 0 gal <br />T 39- — 1?+000 gal <br />A 39- <br />N 39- <br />K 39- <br />39- <br />PHONE # (209) 572-0900 <br />CHEMICALS STOR CURLY/PREVIOUSLY DATE UST INSTALLED <br />unleadeDdRENTEas- uk <br />dip,sel fjIP1 _ _uk <br />L _ APPROVED G' APPROVED WITH CONDITION(S) _ DISAPPROVED <br />A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N <br />PLAN REVIEWER'S NAME DATE <br />tutll�tlnlllnrtlltnlllltltntrutlltntttltttllltnululllllllllllnnlltlttlulttlltllllltllluttllulttlltlttlttlttltt <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 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORN1A,-!t.� r t <br />APPLICANT'S SIGNATUREI <br />CONDITION(S).- <br />IN <br />ONDITION(S)1EN 23 046 (RBvitrd 9/11/90 / P89 3 <br />TLE Contractor/Agent DATE 2/23/98 <br />