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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _ REMOVAL _ TEMPORARY CLOSURE X CLOSURE IN PLACE <br /> EPA SITE rrPROJECT CONTACT i TELEPHONE r Bob Kubend ( 209 ) 946-8288 <br /> F FACILITY NAME Production Chemical Manufacturing, Inc . fN011E r <br /> ACA <br /> C ADDRESS 1000 East Channel Street , Stockton , <br /> I <br /> L CROSS STREET Union Street <br /> I <br /> T OWNER/OPERATOR PHONE r ( 209 ) 943-7337 <br /> Y Lewyn Boler <br /> C CONTRACTOR NAME Turner Explorations PHONE r ( 916 ) 852-74.54 <br /> 0 <br /> N CONTRACTOR ADDRESS 3241 Fitzgerald Rd. , Ste . 2 G Ltt t 602720 fust C-57 <br /> TWORK.COMP.r WCP60827A <br /> R INSURER Superior National Insurance <br /> A PERMIT r <br /> C FIRE DISTRICT <br /> T PHONE r 510 ) 798-1620 <br /> 0 LABORATORY NAME McCampbell Analytical ( <br /> R Geological Audit Services , Inc . - <br /> SAMPLING FIRM g PHONE r <br /> 1IIIIIIIIIIIIIIIIIIIIIIIIII��I <br /> 39- I U44K(� lr 1 UUUN jStllE. CUENledd2C1,� kerO Sr ne 10USLT DATE 1147 INSTALLED <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- T <br /> IIII <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> IIIIIIIIIIIIIIIIIIII VIII <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: NI CERTIFY THAT IN <br /> THE PERFORMANCE OF THE YORK FOR WHICR THIS PERMIT IS ISSUED, I SHALL 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 TNI PERMIT 19 ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIfW1lA.N _ <br /> 2 - <br /> APPLICANT'S SIGNATURE TITLE �/ i DATE -� <br /> EH 23 046 (Revised 7/10/92) Paye 3 <br /> EH 23 032 (REVISED 10-28-93) ' <br /> Date: R PI"!1iT I: t. i S ARE ITO 2 7 U <br /> "FIRE DEPART R . ,- r , <br /> ON DIVISION <br /> 180 DAYS. t RT E .T <br /> �i]CANT MAY RES lig AilADDITIONAL CHARGE , <br />