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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PER&UT <br /> THE PERMIT FOR•PERMANENI/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE Of UNDERGROUND HAZARDOUS SUBSTANCO STORAGE TANK <br /> EXPIRES 90 OATS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYP1 161.0147 <br /> x REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE MCAC 001 359464 PROJECT CONTACT i TELEPHONE M Jim Thorpe 011 , Inc. (209) k8 175 <br /> > FACILITY NAME Sm West Liquors PHONE q <br /> A (209)333-1036 <br /> C ADDRESS 2449 W. Kettlemn Ln. , Lodi CA 95242 <br /> L CROs! STREET Lower Sacrarnento Rd. <br /> I <br /> I OWNER/OPERATOR PHONE / <br /> Y James Anagnos (209)333-1036 <br /> C CONTRACTOR NAME J 1 m Thorpe 011 , •1 tic. PHONE / <br /> 0 209) 368-6175 <br /> N <br /> CONTRACTOR ADDRESS p, 0, Box 351, Lod 1 , CA 95241 CA L IC N 495 fi9g CLASS A B, Haz. <br /> R INSURER firemans rand/Genstar NORK.COMP.0 001197-97 <br /> A <br /> C FIRE DISTRICT The City of Lodi PERMIT E Upon Approval <br /> t <br /> o LABORATORY NAME Geollnal tical Labs COUNrT in PHONE i (209) 572-0900 <br /> R <br /> SAMPLING <br /> FIRM �qI i cal Laboratories PHONE N (209) 572-0900 <br /> 19- 10-A mals. <br /> CHEM dUA I�YIPP"ouslr DATE usr INSTALLED <br /> A39- �- - �a s• un ea a gasoline i I <br /> N 39• �.�Cl.gale <br /> K 39- <br /> 37- <br /> P <br /> 939- <br /> rnntnmlm�r rmmnIIfII III fill nnm1IlmTrRmTTmTIIIIrwf <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A <br /> M ( EE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER#$ NAMEDATE <br /> rrrtrrlrrrrirrrrrrrrrrrrrrrrrrr�Irrrirrrrlrrrr�rrrrrrrrrrrrrrirrrrrrrrrrrrrrrrrrrrrrrrlrrrrrrrrlllllllllllllli�IlrrIrIIIIIIrr <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS Of <br /> $AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES INS FOLLONIN07 "1 CERTIFY THAT IN <br /> THE PERFORMANCE Of THE WOW% FOR WHICH THIS PERMIT 1$ 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 CERIIFIES THE FOLLOWINat <br /> "1 CERTIFY THAT IN THE PERFORMANCE Of IHS (FORK FOR WNICH THIS PERMIT 11 ISSUED, I $HALL EMPLOY PERSONS SUOJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA <br /> APPLICANT'S fIGNATUREI TITLE Contractor/Agent DATE _t�1- 2:.Y. <br /> CONDITIONMI (' w G`3r� -"M Ac:� ?rSV 3!;,57,f sa� <br /> IN 23 046 (Reviled 9/11/94) Page 3 <br />