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SAN JOAQUiN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERNIIT <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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW$ <br /> )( REMOVAL __ TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE #CA0002102104 PROJECT CONTACT S fELEPNOH! N Jjm Thorpe Oil , Inc. (209) 368-6175 <br /> � <br /> F FACILITY NAME Van De Pol Enterprises PHONE N <br /> (209)466-5921 <br /> ADDRESS 3230 N. West Lane, Stockton , CA 95204 <br /> L <br /> 1 CROSS STREET Alpine Ave. <br /> T OWNER/OPERATOR <br /> Y Van De Pol Enterprises PHONE (209)466-5921 <br /> OL CONTRACTOR NAME Jim Thorpe Oil , -Inc. PRONE N <br /> (209) 368-6175 <br /> i CONTRACTOR ADDRESS p, 0. Box 357, Lodi , CA 95241 CA LIC x 495699 cLASB <br /> R INSURER A, B, Hat. <br /> A Genstar /A � � WORK.COMP.N 007197-91 <br /> C FIRE DISTRICT <br /> T ton PERN17 S ul2on approval <br /> N LABORATORY NAMEGe OAnalytical Labs COUNTY San Joa U{n PHONE S <br /> 9 (209) 572-0900 <br /> SAMPLING FIRM g M 1 tical Laboratories PHONE N (209) 572-0900 <br /> - nIIIIIIflIII 111 l�llljn1ll <br /> 19 I0 1bO�'bE 5a CtffliC 8T2R1B6URRENTLY/PREVIOUSLY DATE W INSTALLED <br /> T 39- — <br /> A 39- u g k---- <br /> N 39- in , nnn diasaI f Tal I <br /> uk <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39-39-P IIIIfTTTiTT1T1TTTTTIITTTiTiiT1 fi1TTTTlTTTiTTaTT,TTTTTTiTTfTTTT1T fTmTfffflTTTf(1TfiTITiTiiT111TfiiTTifTiiTTTiR <br /> L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A �42 ( EE CONDITIONS BELOW ANO/OR OH ATTACHMEHi) <br /> N <br /> PLAN REVIEWER$$ NAME _ <br /> DATE <br /> — IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII III III111111111111111111111111111111111111111111111111111111111111 <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 FOLLOWINGS "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WNICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS 70 BECOME <br /> SUBJECT TO WORKER'S COMPENSATION TAUS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWINGS <br /> "I CERTIFY THAT IN THE PERFORMANC THE WOR WHICH T IS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL IFORNIA <br /> I <br /> APPLICANT'S SIGNATURE$ ITLE Contractor/Agent DATE 9/15/98 <br /> CONDITION(S)i <br /> A l crL <br /> ao <br /> PL <br /> IN 23 046 (RBvIRRd"9/1T/961( U Page 312ktce , <br />