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SAN - 6QUIN COUNTY PUBLIC HEALTP SERVICES <br /> ENVIRONMENTAL HEALTH DIVI.-ON <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 /> i] REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPASITE# CAC 00256390d PROJECTCONTACT Jim Love Tr stee PHONE# 1 <br /> FACILITYNAME James King Trust I PHONE# (209)951-5001 <br /> ADDRESS 541 E. Harding Way <br /> CROSSSTREET California St. <br /> OWNEROPERATOR James King Trust PHONE# (209)951-5—OOT- <br /> CONTRACTOR <br /> 209 951-500CONTRACTOR INFORMATION <br /> CONTRACTORNAME lm Thorpe Oil, Inc. PHONE# 209)368-Q175 <br /> CONTRACTOR ADDRESS P Rox q-7CA LIC#, _¢a556Cj CLASS A B HAZ <br /> INSURERAmerican Internat ' 1 Spec Lines WORKER COMP# State 1`'Una 1671173-02 <br /> FIRE DISTRICT PERMIT# Upon Approval <br /> LABORATORYNAME GeoAnal tical Labs COUNTY Stan I PHONE# (209) 572-0900 <br /> SAMPLING FIRM GeoAnalytical Labor tories I PHONE # (209)572-0900 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- p7/�-612 500 gal Leaded Gasoline ? Unknown <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: '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 THE PERFORMANCE OF TH WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF F NN.' <br /> APPLICANTS SIGNATURE ITLE Contractor DATE <br /> ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME 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 />