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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERNUT <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 CLOSIIRF n nenoo m m &tee <br />EPA SITE #CAL 000127922 <br />PROJECT CONTACT d TELEPHONE # Jim Thorpe Oil, Inc. (209) 368-6175 <br />F FACILITY NAME Ta lured Tours <br />PHONE # <br />A <br />2 _ <br />1 ADDRESS 303 E. Ket lem n Ln. Lodi. <br />I <br />L CROSS STREET Washin ton St. <br />1 <br />T OWNER/OPERATOR <br />PHONE # <br />Y Arnie Taylor <br />(209)334-3452 <br />C CONTRACTOR NAME Jim Thorpe Oil, -Inc. <br />PHONE # (209) 368-6775 <br />D <br />N CONTRACTOR ADDRESS p 0. Box 357, Lodi, CA 95241 <br />CA LIC # 495699 <br />class A, B, Haz. <br />I <br />R INSURER Genstar/WORK.COMP.# 007197-97 <br />A <br />C FIRE DISTRICT The City of Lodi I PERMIT # upon <br />T approval <br />0 LABORATORY NAME GeOAnal,ytlCal Labs <br />CDUNTY San JOd(IUIn PHONE # (209) 572-0900 <br />R <br />if FIRM jfi1111116tlical Laboratories PHONE # (209) 572-0900 <br />TANK ID # T SIZE CHEMSTORED URR NTLY PREVIOUSLY DATE UST INSTALLED <br />ICALS <br />22.--'/- 10,06 <br />39- gallons dif <br />esel uel u <br />T 39- 2267- 7_ <br />12,000 gallons f11PCPT f„el <br />A 39- <br />u� <br />N 39- <br />K 39- <br />39- <br />39- <br />P 1111 I I I <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />-CONDITIONS <br />A (AE BELOW AND/OR ON ATTACHMENT) <br />,��F <br />PLAN REVIEWER'S NAME 1G DATE <br />N fes" /G`-cVEi+Y�- <br />1I I I I I <br />I I I I I I I I I I I I I I I I I I I1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "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 FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICI THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNI <br />APPLICANT'S SIGNATURE: TITLE Contractor/Agent DATE 9/30/98 <br />CONDITION(S): I) < P'4114 aha 1c;0a,4i Tim A f!51 E1 aQA— -71> jam+° •�" � <br />53ge�7& cIV <br />�n m6i 4w— <br />EH 23 046 (Revised 9/11/96) Page 3 <br />