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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3RD FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT PIPING REPAIR/RETROFIT ____UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />---------------------------------------------------------------------- ----------------------------------------------------------+ <br />EPA sI -CAL 000012884 1 PROJECT CONTACT & TELEPHONE # Martin Thorpe (209)368-6175 <br />F i FACILITY NAME Pacific Pride Card Lock (Lodi) 1 PHONE # N/A <br />A+ __________________________________________ii <br />I --ADDRESS-------351_-N.--Beckman__ Rd._,_- Lodi,__ CA_95249-----------------------------------------I <br />L CROSS STREET Lockeford St. <br />I+- --------------------------------------------------------- <br />T 1 OWNER/OPERATORJim Thorpe Oil, Inc./ Owner PHONE # (209)368-6175 <br />"_!_Van DePolEnterprises_/__Operator___________________---------- (209_)466-5921 <br />C ; CONTRACTOR NAME , PHONE # <br />0 +----------------------- im__ Thorpe -0i 1, -Inc ---------------------------- (209)368-6175 ---- <br />N <br />2 09-)368-6175--- <br />N ; CONTRACTOR ADDRESSCA LIC # CLASS <br />T +-------------------P_.-O_ Box__B.5-7---------------------------------495690------------- A,B_,Iiaz------i <br />R 1 INSURER WORK.COMP.# <br />A------Amex_--intrnl_._-Bp_e_c__Jin_es/-C1ar_endon------+-------------16_7_11_73-02 ------- <br />C ''I OLaboratory•• _________ INFORMATION ______ _ _ _ _ _GeoAnalytical Labs Phone• ______________+____________-__________--_____________-209 572-0900.I <br />T,- - --- _____, <br />0 Sampler: GeoAnalytical_Labs PHONE # (209)572-0900 <br />1 ----- - - - - - ------------------------------------ - - - <br />I ( PHONE # <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T 39- - <br />A 39 • _ a, � 11a Ss601y� <br />line <br />N 39- j pp i p j U_L 6M.-5 t j OO -!�/1 <br />K 39- i A,IJI ) g'�, i diene i 1:'70:1-:711 ii <br />39- q nnn mai i�ll�a,�l�-ne 1t sxa-Qn <br />39- <br />+---�li iiiiiiiii�IM HllH H lH Hi 11 1H IMM1111111 HiiH HH1 11 ����������ii��������������i�� ����liMi i ll iiililiMMMli HH <br />II P <br />L APPROVED APPROVED WITH CONDITION(.*) DISAPPROVED <br />A (SEE W ION <br />N PLAN REVIEWERS NAME DATE <br />iiiiiiiiiii i ill ii ii i 111111 iii i ii � i i iii i ilii 11111 iii Ilii i 111111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY, ENVIRONFffiTTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO ; <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: "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' CAL RNIA." <br />Jim orpe Oil; Inc. <br />by Vice President <br />APPLICANT'S SIGNATURE: TITLE DATE 2/5103- <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br />coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name Jim Thor pe_ -Address P . 0__Box 357_ Lodi, --CA ___Phone #(209)368-6175 <br />1 <br />