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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 p "TEMPORARY CLDSUk CLOSURE IN PLACE <br /> EPA SITE #CA0n I lI PROJECT CONTACT R TELEPHONE #� ( 209 ) 547-9000 <br /> F FACILITY NAME Den'''s Auto Repair PNONE # ( 209 ) 462-1262 <br /> A <br /> ADDRESS 308 S . E1Dorado St. , Bld A, Stockton, CA 95203 <br /> L CROSS STREET Lafayette <br /> I <br /> T OWNER/OPERATOR Mr. Den Ueda PHONE # <br /> Y ( 209 ) 462-1262 <br /> OC CONTRACTOR NAME Valley Environmental Solutions IPHONE # ( 209 ) 547-9000 <br /> N CONTRACTOR ADDRESS P.O. BOX 48, Stockton, CA G LIC # 695643 CLASS A-Haz <br /> T <br /> R INSURER Rollins, Hudig, Hall of MO WORK.COMP.# 1387611 -94 <br /> A <br /> C FIRE DISTRICT City of Stockton PERMIT # <br /> T <br /> 0 LABORATORY NAME McCampell Analytical PHONE # ( 510 798-1620 <br /> R <br /> SAMPLING FIRM Geological Audit PHONE # ( 209 ) 956-0264 <br /> 39- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br /> _ <br /> T 39- a s e <br /> A 39- — � <br /> N 397,' 000 Gasollne <br /> - <br /> K 39- <br /> 39- <br /> 39- <br /> P )-11) ) <br /> L _ APPROVED APPROVED WITH CONDITIONS) __ DISAPPROVED <br /> A , (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME Q DATE <br /> A`PLICANT MUST PERFORM AIA WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE.^,, STATE LAWS, AID RULES AND REGULATIONS OF <br /> -Sir. J�_AOUTP7-WlIK*',-POfv�it kc;.I.e F'--SEKviLp,,. OWN�k OR LICENi0 AGf N`s rt'S'eLt15F!„i t it?er9ta'!`I H�` hU�.L01:YN�t eY CENTIff 'IHAT INS"-' <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: i Fes\ \�y TITLE �.wy DATE <br /> c <br /> Ph( 4D +I urn <br /> Q ( `l 4 f S f((X*c � ah 'a A'f — MO✓��cz i�C <br /> EH 23 046 (Revised 4/26/94) rr � Page 3 GP.X�L�(.r?N <br /> C+ 1N 1' e,S �►pyb� . 13 ct c�`. �e�aJ,�, <br />