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`r <br />\no, <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMTf `) a <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />X_ REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />CONDITION(S): <br />C'� 0,. t (Ij �'�-- <br />OL <br />E9 23 046 9/11/9 9e <br />EPA SITE # CAC 000743816 <br />PROJECT CONTACT d TELEPHONE # Jim Thorpe Oil Inc. (209)368-6175 <br />F <br />A <br />FACILITY NAME Ralph's Market <br />PHONE # (209)464-8371 <br />C <br />I <br />ADDRESS 2122 S. Airport Way, Stockton,CA 95206 <br />L <br />I <br />CROSS STREET Eighth Street <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />Ralph Lee White <br />(209)464-8371 . <br />C <br />0 <br />CONTRACTOR NAME Jim Thorpe Oil i Inc. <br />PHONE # (209)368-6175 <br />N <br />T <br />CONTRACTOR ADDRESSP O- Box 357 <br />CA LIC x 495699 <br />CLAssA,B,Haz. <br />R <br />A <br />INSURERFiremans Fund/Genstar <br />I WORK.COMP.# 1095135 <br />C <br />FIRE DISTRICT <br />PERMIT # Upon approval. <br />T <br />0 <br />LABORATORY NAME GeoAnalytical Labs <br />COUNTY <br />PHONE # (209)572-0900 <br />R <br />IIIIIIIIIIIIIIIIII�IIII��III ical Laboratories <br />TANK ID # I III TANK SIZE <br />PHONE # (209)572-0900 <br />CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- l 064 - <br />331L <br />T <br />39- Yi <br />n <br />a 1ne <br />U '+ <br />A <br />39- — <br />5�nnn gAIIons <br />ga-nlina <br />„L « <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />I I I I I I I I I I I I I I I I I III I I I I I I I I I I <br />I 1-111111111111111111111 I I 1-11111 _111ITTIMI IWITITITIit IT171111 <br />L <br />_ APPROVED X APPROVED WITH <br />CONDITION(S) DISAPPROVED <br />A <br />(SEE CONDITIONS <br />BELOW AND/OR ON ATTACHMENT) <br />N(1 <br />�Q�C('QJ <br />PLAN REVIEWER'S NAME GV <br />DATE <br />IIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIII1111111111 II IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIII <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED <br />AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '+I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />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 CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH IS <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALL FORN[ <br />Contractor/Agent <br />APPLICANT'S <br />SIGNATURE: <br />TITLE DATE <br />CONDITION(S): <br />C'� 0,. t (Ij �'�-- <br />OL <br />E9 23 046 9/11/9 9e <br />