Laserfiche WebLink
- 0 a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTII SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENUTEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW& <br /> X REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SIIE N CAC, 001350872 PROJECT CONTACT L TELEPHONE N Jim Thorpe 041 , Inc. (209) 368-6175 <br /> F FACILITY NAME Vivian Gatzert Property PHONE N (209)365-6852 <br /> A <br /> C ADDRESS 500 E. Oak St. Lodi CA 95240 <br /> 1 <br /> L CROSS STREET Garfield St. <br /> I <br /> 1 OWNER/OPERATOR PHONE N <br /> Y Vivian Gatzert (209)365-6852 <br /> C CONTRACTOR NAME Jim Thorpe 011 , Inc. PHONE N (209) 368-6175 <br /> 0 <br /> N CONTRACTOR ADDRESS P. 0. Box 357 , Lodi , CA 95241 CA LIC N 495698 CLASS A, B, Haz . <br /> R INSURER Firemans Fund/Genstar WORK.COMP.N 007197-97 <br /> A <br /> C FIRE DISTRICT The Cit Of Lodi PERMIT N upon approval <br /> T <br /> 0 LABORATORY NAMEGeoAnalytical Labs couNT'r San Joaquin PHONE N (P09) 572-0900 <br /> R GG qq�� tt PHONE N (209) 572-0900 <br /> 111111111111111111r19111�II�IITcal Laboratories <br /> TANK ID TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 550 di ese.I Ilk <br /> 1 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 1rrmrlmnrrirrrntmnmrrr nmrm <br /> P <br /> L _ APPROVED 0 APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AHD/OR ON ATTACHMENT) / <br /> M PLAN REVIEWER'S NAME 4T44- �1Kcye,o- DATE <br /> — illlllllllllllllllllllllilllllllllllllllllllillllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll <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 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 fOLLOWINOI <br /> "1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SMALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS Of CALIFORNI - <br /> APPLICANT'S SIGNATURE& _ 1 Contractor/Agent DATE 3/9/98 <br /> CONDITION(S)( J O.K. F4e role C-AJ_ To IIi�Avl. -TAT TPvR[_ AS [ G /AS ET e <br /> uA s-re 44 L L q0--p / �'J Gw t77� �•T..'S-C' �s G T <br /> EN 23 046 (Revised 9/11/90 Page 3 <br />