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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 90T WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # PROJECT CONTACT i TELEPHONE # Helmick & Lerner (916)485-7222 <br /> F FACILITY NAME Don Ave. Pump Station PHONE # N/A <br /> A <br /> C ADDRESS Don Ave Stockton Ca.95202 <br /> I <br /> L CROSS STREET <br /> I nnn Ave And Hammer Lane <br /> T OWNER/OPERATOR PHONE # <br /> Y City of Stockton (209)944-8829 <br /> C CONTRACTOR NAME PHONE # <br /> 01prner (916)485-7222 <br /> N CONTRACTOR ADDRESS 3750 Auburn Blvd. Sac G LIG # 589667 CLASS A-Haz <br /> T <br /> R INSURER WORK.COMP.# <br /> A 1166709-9Z <br /> Fund <br /> C FIRE DISTRICT <br /> T n Joa nine County " PERMIT # <br /> 0 LABORATORY NAME PHONE # <br /> R (916)956-0264 <br /> SAMPLING FIRM Geological Audit PHONE Al (916)956-0264 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE(ySJ INSTALLED <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APP@0 D APP YIJ TI (I _ DISAPPROVED <br /> A ^'?(S(;E AT Mj(V.IYDMDT IONS) <br /> N PLAN REVIEWERS NAME �- G 1 1. DATE .� <br /> APPLICANT MUST PERFORM ALL (ARK-'IN ACCORDANCE WITH SAM JOAOUIM 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, 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 /> APPLICANT'S SIGNATURE: / `��f�dce_ �i( al�sbl TITLEOperationS Manaqer DATE 8-17-93 <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />