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SAN „_,JUIN COUNTY PUBLIC HEALThv,.,,:VICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: ❑ REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- D Leaded Gasoline 17nknown 39- 39- 39- 39- 39 - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I 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 TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE P FORMAN OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF F lN1A." APPLICANTS SIGNATURE ITLE Contractor DATE 7/24/01 ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED J /(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME ] L /�/ DATE7-_15-m 41 1 ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: © � 111-P� � /.il , FACILITY INFORMATION CONTRACTORNAME Jill] Thorpe EPA SITE# CA002383686 r PROJECT CONTACT PHONE# (209)466-5311 209 6- FACILITYNAME FACILITYNAME Cancun Re Staurant Parking Lot PHONE# N/A ADDRESS 342 N. Hunter WORKERCOMP# 046 Unit 7197 CROSS STREET Miner Stockton PERMIT# U On a royal OWNEROPERATOR St. John's Episcopal Church PHONE#(209)466-6916 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- D Leaded Gasoline 17nknown 39- 39- 39- 39- 39 - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I 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 TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE P FORMAN OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF F lN1A." APPLICANTS SIGNATURE ITLE Contractor DATE 7/24/01 ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED J /(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME ] L /�/ DATE7-_15-m 41 1 ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: © � 111-P� � /.il , CONTRACTOR INFORMATION CONTRACTORNAME Jill] Thorpe Oil Inc. PHONE# CONTRACTOR ADDRESS P.O. BOX 357 CAUC#49569 CLASS INSURERKeID er & Gen Star WORKERCOMP# 046 Unit 7197 FIRE DISTRICT The City Of Stockton PERMIT# U On a royal LABORATORYNAME GeoAnalytical Labor atorl SOUNTY Stan PHONE#(209)572-0900 SAMPLING FIRM GeoAnalytical Laborato-ries PHONE # (209)572-0900 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED 39- D Leaded Gasoline 17nknown 39- 39- 39- 39- 39 - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I 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 TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE P FORMAN OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF F lN1A." APPLICANTS SIGNATURE ITLE Contractor DATE 7/24/01 ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED J /(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME ] L /�/ DATE7-_15-m 41 1 ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: © � 111-P� � /.il , EH 23 046 (REVISED 10/19/GBl o�..e