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JOAQUIN COUNTY <br /> HEALTH SERVICES <br /> OVIRON ENTAL HEALTH DIVISION!' <br /> R 0.Box 2009, STOCKTON, CA 95021 <br /> PHONE: (209)468.3420 <br /> Approved <br /> r1 Approi) r' tvith changes: See Re T)arks <br /> See Renr;afjjW <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGETANKCLOSIJR (or <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UND'E flU BSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITEI IN ANY- E�4. INDICATE�PERM <br /> - :, .- <br /> REMOVAL TEMPORARY CLOSURE �-OC OS�IRE IN PLACE <br /> EPA SITE # CAL000152228 PROJECT CONTACT & TELEP146k is C �ctor .(209);.46dtes loot 1.6pso <br /> F FACILITY NAME ' i0,lYi10Nf+ #� "iI iv " Sion <br /> A J & L Market Of dEVla <br /> C ADDRESS 8115 South E1Dorado Street, French Cam , )t '194PM%p-�95231 aws nf <br /> I <br /> L CROSS STREET Matthews Road <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y James Fisk (209) 982 0897 <br /> C CONTRACTOR NAME PHONE # <br /> 0 Flitp TV Cnntractors, Tor. (2nq) 461 6,337 <br /> N CONTRACTOR ADDRESS 2736 Teepee Drive, Stockton,Ca CA LIC # 660076 CLASS A,B,C-10,HaZ <br /> T <br /> R INSURER -t� � � / ,. WORK.COMP.# %jc�/7 <br /> A <br /> C FIRE DISTRICT French m PERMIT # <br /> .ABORATORY NAME Excel Chem Environmental Lab. PHONE # (916) 773 3664 <br /> R <br /> SAMPLING FIRM Upg radient Environmental Consultants PHONE # (916) 452 2891 <br /> 111111111111111111111111111111 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- i 3-C3 1g nnn Eipleade', gasse!iRe est. 1°82 <br /> T 39- ?, <br /> A 39- Unled ed yabal ine es t. t982 <br /> N 39 unleaded gasoline est. <br /> K 39- <br /> 39- <br /> 39- <br /> P IIIIIIIIIIIIIIIII I II II I IIIIIIIIIIIIIIIIIIII <br /> L APPROVED 70PROVED WITH CONDITIONS) DISAPPROVED <br /> A , (SEE ATTAC -ENT WITH CONDITIONS) �. <br /> N PLAN REVIEWERS NAME - Lr,%- l,- - ,t,_ DATE <br /> IIIIIIIIIIIIIIIIIIII IIIII <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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE L DATE -411 -yJ <br /> Tim Gipson, Contract r Owner's Agent <br /> EH 23 046 (Revised 4/26/94) Page 3 <br />