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- I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <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 SITE PROJECT CONTACT i TELEPHONE N Jim Thorpe Oil , Inc. (209) 368-6175 <br /> .�. <br /> F FACILITY NAME <br /> A ' PHONE N (209)334-6144 <br /> C ADDRESS <br /> 1 Lodi CA 95240 <br /> L CROSS STREET <br /> 1 <br /> T OWNER/OPERATOR Kevin Reilly PHONE N <br /> Y y (209)334-6144 <br /> C CONTRACTOR NAME ,Jim Thorpe Oil , -Inc. PHONE M <br /> 0 (209) 368-6175 <br /> N CONTRACTOR ADDRESS p. 0. Box 357, Lodi , CA 95241 cA Llc N 495699 CLASS A, B . Haz. <br /> r <br /> R INSURER Firemans Fund/Genstar WORK.COMP.N 007197-97 <br /> A <br /> C FIRE DISTRICT The City of Lodi PERMIT 011 Tl <br /> T approval <br /> 0 LABORATORY NAMEGeoAnalytical Labs COUNTY Sdn JOd Uln PHONE N <br /> R q (209) 572-0900 <br /> SAMPLING FIRM 1 Lical Laboratories PHONE N (209) 572-0900 <br /> IIIIIIIIIIIIIIIII (19 111411 <br /> TANK ID TANK SIZE CHEMICALS STORED CURRENT"'PREVIOUSLY DATE UST INSTALLED <br /> 39- _ 10.000 gallons _ unleaded e'Sol <br /> ina „k <br /> T 39- _._..10.(1110 mal lnnc l <br /> A 39- �Q uuu gallons un ea e Baso lne 1 <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P nnfTTTTTTTTTTTTTTTITTTITTTTi TTTTTTTTTTiTTTTTTTTTTITTT1TT171T TTiTT1TTi1TTiTTT TTTTTTTiTTTiTTTTTTTTI <br /> L APPROVED - APPROVED WITH CONDITION($) DISAPPROVED <br /> A (SEE CONDITIONS BELOW ANO/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAME r.�lL /�--_ �. . <br /> DATE <br /> I I111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CCUNTY 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, 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 FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH .THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." !� <br /> APPLICANT'S SIGNATURE: T E Contractor/Agent DATE S�l� <br /> CONDITiON(S); �9cs-i�l GO' ( <br /> � S�Tv�Tj 6iiG� k TiTG <br /> F�Qv e/ �4,.1WG rrsi�j 05.66 /�'oCrs b�� y <br /> Z) i4 �C�G>I7l�✓/1�/ G.'r TPC t[,il��G)i�VOT.r3�c' JS�'c�,6A�' LVT/L .9 LL <br /> EN 23 046 (Reviled 9/11/96) Peg* 3 <br />