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e <br />ll <br />I <br />�nxjlyElAPPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING OR PIPING REPAIRp� CC� <br />' <br />THIS PERMIT EMM 90PE MDAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE 414pB((IOW <br />X_TANK REPAIR/ RETROFIT TANK LINING PIPING <br />IRtJNMENTAi_ HEALT4-1 <br />PERMIT/SERVICES <br />39 1 GALLONS <br />39 <br />APPROVED APPROVED WITH CONDITIONS DISAPPROVET, <br />(SIZ AITATC:rWITH CONDITIONS) <br />PLAN REVIEWER'S 1 DATE: <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES <br />AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I <br />SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF <br />CALIFORNIA." CONTRACTOR'S HIRING OF SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />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: TITLE: CONTRACTOR DATE: 2/24/95 <br />EH 23 046 (Revised 1/02/95) <br />EPA CITE#: CAC 7 <br />PROJECT CONTACT & PHONE # RICHARD THORPE (209)368-6175 <br />A <br />FACILITY NAME: JIM THORPE OIL, INC. <br />PHONE # (209)368-6175 <br />c <br />I <br />T <br />ADDRESS: 351 N. BECKMAN RD., LODI, CA 95240 <br />i <br />CROSS STREET: LOCKEFORD ST. <br />T <br />Y <br />OWNER/OPERATOR: VAN DE POL ENTERPRISES <br />PHONE# (209)466-5921 <br />CONTRACTOR NAME: JIM THORPE OIL., INC. <br />PHONE# (209) 4624581 <br />c <br />ADDRESS: 351 N. BECKMAN RD. PO BOX 357 <br />CA LIC#: 495699 <br />CLASS: A.B. HAZ <br />O <br />N <br />T <br />INSURER: LANDMARK & GENSTAR <br />WORK COMP# <br />STATE COMP. INS. FUND -1095135 <br />R <br />A <br />OTHER INFORMATION <br />c <br />PHONE# <br />T <br />O <br />PHONE# <br />R <br />TANK ID# TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />T <br />A <br />39 GALLONS <br />N <br />K <br />39 GALLONS <br />39 1 GALLONS <br />39 <br />APPROVED APPROVED WITH CONDITIONS DISAPPROVET, <br />(SIZ AITATC:rWITH CONDITIONS) <br />PLAN REVIEWER'S 1 DATE: <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES <br />AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I <br />SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF <br />CALIFORNIA." CONTRACTOR'S HIRING OF SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />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: TITLE: CONTRACTOR DATE: 2/24/95 <br />EH 23 046 (Revised 1/02/95) <br />