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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMAME11I/1EMPORARY CLOSURE OR ABANDONMENT IN PLACE Of UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> IRIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE TN ANY SHADED AREAS. INDICATE PERMIT TYPE SELOWT <br /> /A✓G REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE r GAG 00088 888 PROJECT CONTACT R TELEPHONE r (209)368-8080 <br /> f FACILITY NAME Lloyd GumLs PHONE r (209)368-8080 <br /> A <br /> t ADDRESS <br /> I 303 'L Cherokee Ln. Lodi, CA Q524n <br /> L CROSS STREET Lodi Ave. <br /> I <br /> I GDIER/OPERAIOR PHONE r <br /> I Same as above Same as above <br /> C CONTRACTOR NAME J111I '1'Ilor-pe Oil I Inc. - PHONE r (209)462-1#581 <br /> 0 <br /> N CONTRACTOR ADORF"351 N Beckman IN. P.O.Bx. 357 G TIC r 4 5 cuss <br /> IRER a e <br /> R IHSIpomp. ns. u d <br /> Firesnrnls Fund/ Pacific Insur. Co. , LTD WORK COMP.r <br /> A <br /> C FIRE DISTRICT City of Lodi PERNII Bon aporoval of plan <br /> 1 <br /> 0 LABORATORY NAME Geokem Mobile Labs PHONE r (209)537-7836 <br /> R <br /> SAMrI ING FIRM Same as above PHONE r (209)537-7836 <br /> — IIIIIIIIIIIIilll�lllllllllll <br /> TANK ID TANK 312E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 1 39- <br /> A 39- <br /> N 39- <br /> K 39- _ <br /> 39- <br /> - liiinnnnnnnnnnnnn nrnnnrrnmrrnnrnrnnrr Milli III fill"IIIIII[fill III I till"Iti IrmrrmrrmIII fill <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> Ac EE ATTACHMENT WITH CONDITIONS) <br /> DATE <br /> N PIAN REVIEWERS NAME <br /> — nnnnnlnllnlnrrn�inrrnnnmr- -rirrirnnrrrmnnrrnrrnrrrnrrrrrrntirrminnrrrr TfliilTrlrrrrrlliirr <br /> APPLJ GRT MUST PERFORM ALL MIRK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS Of <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER GR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINGS -1 CERTIFY THAT IN <br /> IRE PERFORMANCE OF THE NARK FOR WHICH THIS PERMIT IS ISSUED, 1 SMALL 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 CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE O THE WORK FOR VNIC THIS PERMIT IS ISSUED, T SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS Of GLIFORN 7 Cy <br /> APPLICANT'S SIGNATURES r TITLE COIILraGLor DATE <br /> IN 23 046 (Revised 7/10/92) Page 3 <br />