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SAN ,QUIN COUNTY PUBLIC HEALT ERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> tI REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#CAC002559617 I PROJECT CONTACT Jim Frankel PHONE#(209)943-8550 <br /> FACILITY NAME The Stockton Record PHONE K 209 943-8550 <br /> ADDRESS 530 E. Market St . , Stockton, CA 95202 <br /> CROSS STREET az-c// 4px_4)1 k S <br /> OWNER OPERATOR Stoexton ewspapers, Inc. PHONE 4(209)943-8550 <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME 1111 Thorpe Oil, Inc . PHONE# 209 368-6175 <br /> CONTRACTOR ADDRESS - r CA LIC#, _.49,56c_i_cL I CLASS A B HAZ <br /> INSURERAmerican Internat ' 1 S ec.Lines WORKERCOMP# State Puna 1671173-02 <br /> FIRE DISTRICT PERMIT# Upon Approval <br /> LABORATORY NAME GeoAnalyt ical Labs COUNTY Stan I PHONE# (209) 572-0900 <br /> SAMPLINGFIRM GeoAnal tical Laboratories PHONE # (209)572-0900 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- 10 ,000 gal unleaded gasoline unknown by Cont 'r_ <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S CO ENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLL014ING: "I CERTIFY THAT INTtERFORMANCE OF T E WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS 0 IA." <br /> APPLICANT'S SIGNATURE LE Contractor DATE 12/9/02 <br /> ❑ APPROVED PPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME C/t.��L <br /> SEE <br /> C" DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> G tfa C u_A 0 n Cll`1 T in <br /> EH 23 046(REVISED 08/13/99) Page 3 <br />