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..i <br />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 DAT DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE Ga-// 7,740o <br />PROJECT CONTACT 8 TELEPHONE # Bill L1LLle 40 i- 1 vvv <br />1 <br />F <br />FACILITY NAME Martini Automotive <br />PHONE # 462-8696 <br />A <br />4032 North Eldoado <br />Street <br />C <br />ADDRESS <br />I <br />L <br />CROSS STREET Churchill <br />I <br />PHONE # 46208696 <br />T <br />OWNER/OPERATOR Mike Ma ini <br />I <br />Y <br />C <br />CONTRACTOR NAME Advanced Geo <br />Environmental <br />PHONE # 467-1006 <br />-A <br />0 <br />N <br />CONTRACTOR ADDRESS 4005 North Wilson Way <br />cA LIC x 680227 <br />CLASS a2 <br />T <br />St. Paul Fire and <br />Marine/ Design Prof. INS <br />- <br />WORK.COMP.# <br />R <br />INSURER <br />A <br />C <br />FIRE DISTRICT Stockton <br />PERMIT # <br />T <br />0 <br />LABORATORY NAMEMC Campbell <br />COUNTY Contra Costs <br />PHONE x 925798- 1620 <br />R <br />ue en erson <br />eg1S ere PHONE # 467-1006 <br />SAMPLING FIRM <br />TANK ID # <br />TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39-e <br />T <br />39- <br />Qa on <br />suspectWas <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />L <br />A <br />APPROVED <br />APPROVED WITH CONDITION(S) DISAPPROVED <br />CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N <br />/ 6 <br />I(SEE <br />PLAN REVIEWER'S NAME <br />/� DATE t <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. <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS <br />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 <br />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 CALIFORNIAL.".1 <br />APPLICANT'S <br />SIGNATURE: (y ,v- <br />Z�'y/�%J TITLE li ATE <br />CONDITION(S): -S c y �, �/, S ^ <br />� � {..f-,� f r s� <br />1- <br />9 ) <br />� a <br />EH 23 046 (Revised 9/11/Page 3 <br />