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NC- IobA.yp-zCI � <br /> ffENVIRONMENTAL HEALTH DIVISION <br /> 111,30 <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT MAR 1 9 1992 <br /> DLICATION FOR DERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HA RI�I��p 'pEwoow- '�.�0(t}{�TY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE iN ANY SHADED AREAS. 1 'IVIL'1-� ,I�,TXGE•)3�OW. <br /> X REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE M CALOO00351918 PROJECT CONTACT i TELEPHONE M JIM HOBLITZELL 463 7108 <br /> F FACILITY NAME CITY OF STOCKTON,SWENSON PARK GOLF COURSE PNaNE r 477 0774 4 qqloS°o-S <br /> C ADDRESS 6803 ALEXANDRIA PLACE, STOCKTON, CALIFORNIA 95207 <br /> 1 <br /> L CROSS STREET BENJAMIN HOLT <br /> I PHONE M <br /> T OWNER/OPERATOR CITY OF _$TOCKTON <br /> Y PHONE 0463 7108 <br /> C CONTRACTOR NAME FALCON ENERGY ���}�/� <br /> 0 D� CA LIC w 584524 CLASS it All us <br /> N CONTRACTOR ADDRESSP 0 DTIX IZS7,STOCKTON, CA 95201 <br /> T WORK.COMP.N <br /> R INSURER ON FILE <br /> A PERMIT M <br /> C FIRE DISTRICT CITY OF STOCKTON CII �M <br /> T PHONE Y (415) 36-1 9600 <br /> 0 LABORATORY NAME SEQUOIA AANALYTICAL p58 +�Cn <br /> 3507 <br /> R <br /> SAMPLING FIRM DATER WORK (RESNA) 8 <br /> PHONE k (209) <br /> 111111111111111111111111111111 TANK S12E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK ID k <br /> 39- <br /> T 39- <br /> A 39• <br /> N 39- <br /> 39- <br /> 39 <br /> 9- <br /> 39•39 <br /> 39• <br /> -------- <br /> P APPROVED APPROVED <br /> lliilll111111111111 <br /> PAPPROVED WITH CONDITION(S) __ DISAPPROVED <br /> L __ APPROVED <br /> (SEE ATTACIMENT WITH CONDITIONS) <br /> A DATE <br /> N PLAN REVIEWERS NAME <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIllIIIIIIIIiIIIIIIII1111111111111111111111111111111111111111111111111111ES AND REGULATIONS <br /> 111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JMOUIN 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: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOYOf ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> OACONTRACTOR'S <br /> HIRSMALL` SIGNATURE ETNFOLLOWING <br /> SIBJCTOTSTERS � NSATIOLAWSTTHEWORKFORWHICHHIPERMITISSSUED, I EMPLOY PERSONS SUBJECTTOWORKER <br /> ETIANTPENC : <br /> COMPENSATION LAWS OF CALIFORNIA." - <br /> _ TITLEV 'P.L&,1 EW. MGR- DATE <br /> APPLICANT'S SIGNATURE: - REG, ENv, ASSESSOR, RFA,03121 <br /> J S �J. Ho ZELL„ IV <br /> Page 3 <br /> EH 23 046 (Rev 2/8/91) ft <br />