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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 /> YX REMOVAL _ TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE !CA0000698280 PROJECT CONTACT N( TELEPHONE !WESTERN METER SERVICE, INC. 948-612 <br /> F FACILITY MA14E CUSTOM RV PWNE # (209)982-5723 <br /> A <br /> C ADDRESS 4807 AIRPORT WAY, STOCKTON, CA 95206 <br /> I <br /> L CROSS STREET SPERRY—ARCH—AIRPORT TO NORTH <br /> I <br /> T OWNER/OPERATOR PHONE t <br /> Y ART KOROCK (209)982-5723 <br /> C CONTRACTOR NAME WESTERN METER SERVICE, INC. - -PHONE jT7M7M8—rbl 24 <br /> 0 <br /> N CONTRACTOR ADDRESS 2735 TEEPEE DR, STE E. , CA LIC ! 414051 cLAssC61— D40—HAZ <br /> T <br /> R INSURER WORK.COMP.! 1290173-92 <br /> A <br /> C FIRE DISTRICT STOCKT40N CITY (LINCOLN EAST SIDE) 944-8801 PERMIT ! <br /> T <br /> 0 LABORATORY NAME FGL ENVIRONMENTAL PHONE ! (209)942-0181 <br /> R <br /> SAMPLING FIRM SAME PHONE ! SAME <br /> TANK ID ! TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39• /S –1 12,000 GALLON -DIESEL GASOLINE LAST 1982 <br /> ! – , —�%U— <br /> T 39- <br /> A 39- — G — EL LAT <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> D <br /> L �L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME ! – DATE <br /> APPLICANT MUST PERFORM ALL YORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "N CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAYS 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.• n <br /> APPLICANT'S SIGNATURE: ` TITLc C- el /.//7�1 - DATE <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />