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SANI.,AQUIN COUNTY PUBLIC HEALT' ' SERVICES <br /> ENVIRONMENTAL HEALTH DIVR,fON <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY 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 /> t] REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# CACOO PROJECT CONTACT PHONE# Cqc)q) 945;-24g2 <br /> FACILITY NAME TO PHONE# - <br /> 499, <br /> ADDRESS 767 N. Alpine Rd. . Stockton . CA 95215 <br /> CROSSSTREET Orford Rd. <br /> OWNER OPERATOR Tony JOckvich Trust PHONE# (209)948-2482 <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME Jim Thorpe Oil , Inc. PHONE# 209 68- 1 <br /> CONTRACTOR ADDRESS ^ CA LIC#, _41,1569 CLASS A B HAZ <br /> INSURERAmerican Internat ' lS Spec-Lines WORKERCOMP# State una 1671173-02 <br /> FIREDISTRICT City of Stockton PERMIT# Upon Approval <br /> LABORATORYNAME GeoAnal tical Labs COUNTY Stan PHONE# (209) 572-0900 <br /> SAMPLINGFIRM GeoAnal tical aboratories PHONE # (209)572-0900 <br /> TANK INFORMATION <br /> TANK 10# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- <br /> 39- <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: h <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 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OFLIFORNIA.' <br /> APPLICANTS SIGNATURE vl�ITLE Contractor DATE±/2/03 <br /> [] APPROVED APPROVED WITH CONDITIONS) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME�ll — DATE <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 />