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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <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. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW; <br /> XX REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # 66 <br /> + (Z0 PROJECT CONTACT & TELEPHONE 0 Bill Little 467-1006 <br /> F FACILITY NAME Rosenthal Building PHONE c/o 948-0434 <br /> A <br /> C ADDRESS 24 South American Street <br /> I <br /> L CROSS STREET Main Steet <br /> T OWNER/OPERATOR Rosenthal Trust c/o Bank of Stockton PHONE <br /> Y 948-0434 <br /> C CONTRACTOR NAME Advanced Geo Environemtnal PHONE X 467-1006 <br /> 0 <br /> N CONTRACTOR ADDRESS 837 Shaw Road CA LIC x 680227 CLASS A Haz <br /> T <br /> R INSURER Saint Pau, WORK.canP.01317474-97 <br /> A <br /> C FIRE DISTRICT Stockton CA I PERMIT S <br /> T <br /> 0 LABORATORY NAME Precision EnvirotecCOUNTY san ]oaquin I PHONE '9 462-0892 <br /> R <br /> SAMPLING FIRM same PHONE x same <br /> IIIIIIIIIIIIIIIIIIIillllliltil <br /> TANK ID X TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- I <br /> I1111111111lII111111111! II 1 II I II 1 1 1 1 1 1 1 1 11 1111111illllllllilllll!lllilllll 1111 Iiliilllll <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAME DATE <br /> IIIIIII11111111111111111111111111111I111111111111111111111111111111111111111111111 llllilllllllilill llllilillllllilillll 111111 <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 FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH 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 THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> Bank of Stodctal Th)st Dqmrtrpnt1 as of the Mike PcsEnthal Testma-itat:y Mast, as its inteLast II13y <br /> APPLICANT'S SIGNATURE: ✓ - - P CZM.. _ TITLE, f'rew f'G/ DATE✓3 D/ <br /> f4 Trust Reef k, -3•a/ <br /> CONDITION(S): <br /> E9 23 046 (Revised 9/11/96) Page 3 <br />