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A <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: j <br /> X REMOVAL I TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # CAC 001228128 PROJECT CONTACT � TELEPHONE # Charlie Skobrak (209)465-2667 <br /> F FACILITY NAME Charlies Day & Night Lock Service ?HONE # (209)465-2667 <br /> A <br /> I <br /> ADDRESS 706 N. El Dorado St. , Stockton, CA 95202 <br /> j L CROSS STREET Park St. df <br /> 1 <br /> T OWNER/OPERATOR PHONE #(2O9)465-2667 <br /> Y Charlie Skobrak <br /> C CONTRACTOR NAMEJim Thorpe Oil, Inc. #(209)368-6175 <br /> 0 � <br /> N CONTRACTOR ADDRESS 351 N. Beckman.Rd./P.0. BX 357 CA,,LIC # 495699 CLASS ',.A,B,HAZ j <br /> R INSURER Firemans Fund/General Star VORK.COMP.# 1095135 <br /> A <br /> C FIRE DISTRICT The City of Stockton PERMIT N Upon approval. <br /> T <br /> 0 LABORATORY NAME GeoAnai tical COUNTY,San/JoaQuin PHONE "4209)572 <br /> -0900 <br /> R <br /> SAMPLING FIRMI <br /> 111111111111111111111{111flIII GeoAnal tical Laboratories PHONE 0 (209)572-0900 <br /> A,K ID f� TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39 {� a1 ori ,'1 Id. gasoline uk <br /> T 39-_ 000 id sas;01-i-n6a <br /> S7% <br /> 39- / <br /> 9 39- j <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39- <br /> lfP <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A EE CONDITIONS BELOW AND/OR ON ATTACHMENT)/4 i <br /> N <br /> PLAN REVIEWER'S NAME--L4-4--V--, DATE -7 i <br /> r <br /> IIfill 11fill III fIIIIIIIIIIII{I1{lll1ilOf <br /> IIIIIIIII1111111111�111{I{i1111111III III11111111111II1I111111111111{IIIIIII11111III I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCOIjDANCE WITH SAN JOAQUIN`COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN 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 HIS 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 HIRIHt OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: E <br /> "I CERTIFY THAT IN THE PERFORMANCE D THE WORK FOR WHICH THIS PERMIT IS IS I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI <br /> I <br /> APPLICANT'S SIGNATURE: Contractor DATE 5/14/97 <br /> i <br /> ! <br /> `� -ONDITION(S): <br /> -s <br /> cz� I- <br /> - y J <br /> e ea <br /> F,y 23 046 (Revised 4/11/96) � � page 3 _ � <br />