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SAi.DAQUIN COUNTY PUBLIC HEAL ' SERVICES <br /> ENVIRONMENTAL HEALTH DI�ION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY 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 /> ] REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT Evelyn Pewitt ---T7HONE# (-jqq)qCj5-RQjn <br /> FACILITYNAME Evelyn Pewitt Property PHONE# _ <br /> ADDRESS 6035 Condon Ave. Los Angeles <br /> CROSS STREET Ralph Ave. <br /> OWNEROPERATOR Evelyn Pewitt PHONE# (323)295-8910 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME lm Thorpe l l, Inc. PHONE# 209 368-6175 <br /> CONTRACTOR ADDRESS - CA LIC#, -495( cLAss A B HAZ <br /> INSURERAmeriCan Internat ' 1S ec.Lines WORKERCOMP# State Puna 1671173-02 <br /> FIRE DISTRICT The lty of Stockton PERMIT# U On A royal <br /> LABORATORYNAME GeOAnal tical Labs COUNTY Stan PHONE# (209) 572-0900 <br /> SAMPLING FIRM GeoAnalytical Labor tories PHONE # (209 )572-0900 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- 500 gallor Re ular Leaded <br /> 39- 500 gall-or Premium Leaded Gas Uk <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 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN TH94ERFORMANCE OF TH WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF RNIA.' <br /> APPLICANTS SIGNATURE TITLE Contractor DATE 3/4/03 <br /> ❑ APPROVED AP�P�/JR�O��V�ED WITH CONDITION(S) ❑ DISAPPROVED <br /> I "'' "v � " ""E CONDITIONS BELOW AND/OR ON ATTACHMENT) � R .,/ <br /> PLAN REVIEWER'S NAME ^ DATE-''�7 <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046(REVISED 08/13/99) Page 3 - <br />