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SAN Ji -,AQUIN COUNTY PUBLIC HEALT ;ERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS <br /> ANCES <br /> STORAGE 7ANKO(S)EXPIRES 90�S FROM THE APPROVAL DATE DO NOT WRITE N ANY SHADED Y CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS <br /> INDICATE PERMIT TYPE: <br /> T1 REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE T '�7 3PROJECTCONTACT Mike Vandgrift PHONE#(209)475-998 7 <br /> FACILITY NAME a eway, nc. ue top PHONE#(209)475-9987 <br /> ADDRESS 6425 Pnnifir. Ave - Stnrktnn r A CI c;9.0-7) <br /> CROSSSTREET Douglas <br /> OWNER OPERATOR Safewa Inc. PHONE - <br /> s :. <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Lm Thorpe Oil, Inc- PHONE# 209 368-6173 <br /> CONTRACTOR ADDRESS - CA LIC O :.4`,�'ja 9 CLASS A B HAZ .- <br /> INSURERAmeriCan Internat ' l Spec -Lines WORKERCOMP* StarePuna1671173-02 � <br /> FIREDISTRICT The City of Stockton PERMIT# Upon ADproval <br /> LABORATORYNAM Severn-Trent Labs COUNTY Al ^- <br /> SAMPUNGFiRM orbmacher En. ineerin PHONE k - n � <br /> d <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT iL PA DATE INSTALLED <br /> 39_ 350 gal. Waste Oil Unknown <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUSUC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING_' ''r -. <br /> IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME UIBJECT TO WORKERS COMPENSATICN LAWS OF CAU ORNIA N THE PERFORMANCE OF THE WORK FCR WHICH THIS TCONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECTTO <br /> WCRKER'S COMPENSATIONLAWS <br /> APPLICANTS SIGNATUR �TITLE Contractor DATE 10/21/03 .i <br /> i <br /> ❑ APPROVED APPROVED WITH CONDITION(S) 70DISAPPROVED <br /> (S CONDITIONS BELOW AND/OR ON ATTACHMENT)PIAN REVIEWER'S NAME E v D3ANY DEVIATIONS FROM THIS APPLICATION MUST E SUBMITTED TO EHD FOR APPROVAL PRIOR NCING WORK. <br /> CONDITONS. <br /> EH 23 046(REVISED 08113199) Page 3 - - <br />