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*amp, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UMDERGROUN) STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENTITEMPORARY 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 /> X REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # CAD 982051781 PROJECT CONTACT i TELEPHONE # John Lynch ( 209) 833-0758 <br /> F FACILITY RAMS-racy Joint Union High School District PHONE # ( 209 ) 831-5032 <br /> A <br /> C ADDRESS 315 E. 11th Street Tracy, CA 95376 <br /> 1 <br /> L CROSS STREET East Street <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y Tracy Public Schools Anne Bell ( 209 ) 831-5032 <br /> C CONTRACTOR NAME Wright Environmental Services , Inc . PHONE # ( 209) 833-0758 <br /> 0 <br /> N CONTRACTOR ADDRESS 1961 Hill View Way, Tracy a LIC # 651501 cLAssA , B , HAZMAT <br /> T <br /> R INSURER Adreini Company & Workman ' s Comp. WORK.COMP.# 1312649-93 <br /> A <br /> C FIRE DISTRICT Tracy PERMIT # N/A <br /> T <br /> 0 LABORATORY NAME CKY Environmental/S ar er Tech . PHONE # 91 510 846-3188 <br /> R — <br /> 47 <br /> SAMPLING FIRM Wright Environmental PHONE # ( 209 ) 833-0758 <br /> TANK 10 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DAT7E US 1ySSSA11 D <br /> 39• 1 , 000 aal DiesP f iel 196 -1yb <br /> T 39- <br /> 1 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111111 <br /> N11111111111111 <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A EE TACHMENT WIT ITIONS) 7 �J <br /> N PLAN REVIEWERS NAME DATE <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 YORK 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 YORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAYS OF CALIF fA-• `^14` <br /> 1 Ir <br /> APPLICANT'S SIGNATURE: TITLE ^ i C'�) A e`ti DATE z <br /> * Old Transportation Facility <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />