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SAN JOAQUIN COUN'T'Y 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 /> EMPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOWt <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE 0CAC002102104 PROJECT CONTACT i TELEPHONE N Jim Thorpe Oil , Inc. (209) 368-6175 <br /> F FACILITY NAME Van De Pol Enterprises PHONE 0 (209)466-5921 <br /> A <br /> C ADDRESS 3230 N. West Lane , Stockton , CA 95204 <br /> L CROSS STREET Alpine Ave. <br /> T OWNER/OPERATOR PHONE E <br /> Y Van De Pol Enterprises (209)466-5921 <br /> C CONTRACTOR NAME Jim Thorpe 011 , Inc. PHONE 0 (209) 368-6175 <br /> 0 <br /> N T CONTRACTOR ADORES$ P. 0. Box 357, Lodi , CA 95241 cA LIc 495699 CLASS A, B, Naz. <br /> R INSURER Gens tar /L— WORK.COMP.0 007197-97 <br /> A <br /> C FIRE DISTRICT PERMIT 0 <br /> T ton upon approval <br /> 0 LABORATORY NAMEGeokalytical Labs COUNTY San Joaquin PHONE 0 (209) 572-0900 <br /> R <br /> SAMPLING FIRM GG 1 tical Laboratories PHONE $ (209} 572=0900 <br /> IIIIIIIII II 1ii1111�17MIit�11 <br /> T1 10 ITA"b66E CtIlit qA 8TpRlE�6CURRENTLY/PREVtOUSLY DATE W INSTALLED <br /> 39- .�-- Q U IIJJUUU �a <br /> f 39- i o o o ui Baso i <br /> A 39 t c� 1n non diesel fuel ( u <br /> N 39- ' <br /> K 39- - <br /> 39- <br /> fill�TTf TTTTiT1TiTTTTTi1TTITTI <br /> P <br /> L _ APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A ( EE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAME t� C' DATE <br /> Illllllllllilllliiill1111111llllllfllll11111111111111!! 111 difil fill IIIIfillIIIII Illllfililillilllllllllllllllllillllllllli <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANO REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINGs "t CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL HOT 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 FOLLOWINOt <br /> "t CERTIFY THAT IN THE PERFORMANCTHE WOR WHICH T 15 PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA <br /> ZI <br /> APPLICANT'S SIGNATUREi (TLE Contractor/Agent DATE 9/15/98 <br /> CONDITION(S)t <br /> � H <br /> EH 23 046 (RNvitod 9/41/96) `( J Page V-Kt6t O ! a <br /> y <br />