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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERNIH <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. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL _ TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SIZE ACAC 001 359464 PROJECT CONTACT L TELEPHONE M Jim Thorpe 0�1 , Inc. (209) 368-6175 <br /> A FACILITY NAME Sten West Liquors PHONE N (209)333-1036 <br /> C ADDRESS 2449 W. Kettleman Ln. , Lodi CA 95242 <br /> 1 <br /> L CROSS STREET Loner Sacramento Rd. <br /> I <br /> 1 OWNER/OPERATOR PHONE B <br /> Y James Anagnos (209)333-1036 <br /> C CONTRACTOR NAME Jim Thorpe Oil , -Inc. PHONE B (209) 368-6175 <br /> 0 <br /> N CONTRACTOR ADDRESS p. 0. Box 357, Lodi , CA 95241 CA LIC B 495699 az. <br /> I <br /> R INSURER Firemans Fund/GenstarWGRK.CONP.B 007197-97 <br /> A <br /> C FIRE DISTRICT The City of Lodi PERMIT B Upon Approval <br /> T <br /> 0 LABORATORY NAME GeoAnalytical Labs COUNTY s.ABIB,�in PHONE B (209) 572-0900 <br /> R <br /> SAMPLING FIAN GG 1 tical Laboratories PHONE M (209) 572-0900 <br /> Illululnlnllll�i9 �II�11 <br /> TANK ID SIZE CHEMICuL a d U <br /> 39- a 3 310,ft gals. n �W&TjR VIOUSLY DATE UST INSTALLED <br /> T39- r gals. un ea e Baso ine � <br /> A 39- ln•nnn gals ilnl PAded gn-nl ino <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P IIIIIIIIIIIIIIIIIIlifiTTilTTI <br /> L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHNENT) <br /> M <br /> PLAN REVIEWER'S NAMED DATE <br /> I I I I I I I I I I I I I I I I I I I I I I I I I I I I I111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN CCUNTY 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, 1 SMALL 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 FOLLOWINGI <br /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATIONLAWS OF CALIFORNIA <br /> APPLICANT'S 3IGNATUREI TITLE Contractor/Agent DATE 5— 2- <br /> L-If <br /> CONDCTION(S)i r� /r nS� T/J�1 L' rR y'v S 35 8 AAS] ASSoc-il9:.Sy, 501Li <br /> IM 23 046 (Revised 9/11/90 Page 3 <br />