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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE SELOWI <br /> X REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE S CAC 00131.4624 PROJECT CON[ACTS TELEPHONE N Jim Thorpe Oil , Inc. (209) 368-6115 <br /> A FACILITY NAME The Fannie Mae Foundation PHONE X(209)235-202!? <br /> C ADDRESS 25^33 Eunice Pd. , Acamno, CA 95220 <br /> 1 ' <br /> L CROSS STREET Collier Rd. <br /> I <br /> I OWINER/OPERATOR <br /> T Same as 2.bove PHONE / 7 <br /> (_09)235-2(120 <br /> C CONTRACTOR NAME Jim Thorpe 011 , .Inc. PHONE / (209) 368-6175 <br /> 0 <br /> N CONTRACTOR ADDRESS p. 0. Box 357, Lodi , CA 95241 cA Llc / 495699 cLA/B A, B, Haz. <br /> R INSURER Firemans Fund/Genstar WORK.COMP./ 007197-97 <br /> A <br /> C FIRE DISTRICT <br /> r PERMIT N <br /> oFcQ �0.�A� u nn an rcval <br /> O LABORATORY NAMEGe OAnalytical Labs CouNTY San Joaquin PHONE / (209) 572-0900 <br /> R q <br /> SAMPLING FIRM 1 ical Laboratories PHONE N (209) 572-0900 <br /> — nnnnnnGuIj?()1MVIl[i <br /> TA K I TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> J9- <br /> f 39- <br /> 35n gal Inns gasoline <br /> A 39-_ <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P nnnrrrinmrrimnrmm mrrmrmmmrrrrnnrrrrrr n <br /> L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (S E CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N PLAN REVIEWER'S NAME G�/G/� V15 DATE y <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINGI "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 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 CERTIFIES THE FOLLOWINGT <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA <br /> I <br /> APPLICANT'S SIGNATUREI L-I, TITLE Contractor/AgentDATE 7/8/98 <br /> CONDITION(S)1 I <br /> )� GF.9�60 G45'oG��G �vA9srT�,�.�7y lv�liL�� TiTf6�-4'",.CF/J G9A4 /1--. <br /> IN 23 046 (Rw(Bd 9/11/961 PRBB I <br />