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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />ANCE <br />TANK <br />AP IRISAPERMITOEXPIRESN90YDAYS DAYS THE AAPPROVALADATE. DOTNOT WRITE /N NYESHADEDDARE S. INDI�ETPERMITSTORAGE <br />IN PLACE TYPE ELOW$ <br />v i cmmany rIfmiRE CLOSURE IN PLACE <br />EH 23 046 (Revised 7/10/92) Page 3 <br />J <br />EPA S1TE NCAC 001001248 <br />PROJECT CONTACT i TELEPHONE N m - <br />PHONE N <br />F <br />FACILITY NAME Jefferson School DisIr1Ct <br />- <br />A <br />C <br />ADDRESS Y500 W. Linne Road Tracy, CA 95376 <br />I <br />L <br />CROSS STREET Chrisman <br />I <br />PHONE N <br />I <br />OWNER/OPERATOR <br />Same above <br />(209)836-3388 <br />Y <br />as <br />C <br />CONTRACTOR NAME Jim Thorpe Oil, Inc. <br />7 <br />PHONE N (20 )462-4581 <br />D <br />N <br />CLASS <br />CONTRACTOR ADDRESS351 N Beckman Rd. P.O.BX. 357 G LIC N 4 6 A <br />I <br />R <br />- <br />INSURER [-iresmans Fund/ Pacific Insur. Co., LTD WORK.COMP.N a e romp. ns. u <br />A <br />C <br />FIRE DISTRICT Tracy Rural <br />PERMIT N <br />On approval <br />T <br />0 <br />LABORATORY NAME GeoAnalytical Laboratories <br />PHONE N (209)572-0900 <br />R <br />PHONE R <br />SANPI IMO FIRM <br />111111111111111111111111111111 <br />ANK D N i412E CNEN GLS ST ED CURR NTIY/PREVIOUSLY DATE US7 INSTALLED <br />leaded � UK <br />D/ 500 gaAi�ons gaso> ine <br />T <br />39 <br />39- <br />wu gallons <br />diesei IUVjl <br />ILK <br />A <br />39- <br />39- <br />N <br />K <br />39- <br />39- <br />liiirnnrnrmm�nrrmm nttnmrrrrtntrrrrtnTrrm mmTTmm�TTTTTTnrmmrrrrrrrrr rmTmmmtnTTrr <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A TSFE A ACHMENT VITN (TIONS) <br />N PIAN REVIEVERS NAME <br />— IIIIIIIIIIIIIIIIIIIIIITTTTIIITTTiT I T TTT i11TTIITITIITTTTTTTT(nIIII1TTiTTTI111111111111TiiTT11T1i1 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOUIDUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />NOT EMPLOY ANY PERSON IN SUCH A HARMER AS TO BECOME <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE LARK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF GLIFORNI . <br />APPLICANT'S SIGNATURE: TITLE COntC'actpY' _ DATE '19 /_,�a /9 S1 <br />EH 23 046 (Revised 7/10/92) Page 3 <br />J <br />