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1 <br /> 2 <br /> L�' VONf HEALTH <br /> PGRA11Tira VICES <br /> 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 /> _Y_ REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> jCgADE M CAD 982051781 PROJECT CONTACT i TELEPHONE M John Lynch ( 209) 833-0758 <br /> DRESS <br /> TY NAME racy Joint Union High School District PHONE M ( 209) 831-5032 <br /> 315. E. 11th Street Tracy , CA 95376STREET East Street PHONE M <br /> { OWNER/OPERATOR <br /> Y Tracy Public Schools Anne Bell ( 209) 831-5032 <br /> C CONTRACTOR NAME Wright Environmental Services , Inc . PHONE M ( 209 ) 833-0758 <br /> 0 <br /> N CONTRACTOR ADDRESS 1961 Hill View Way, Tracy CALIC9 651501 1 CLASS A , B , HAZMAT <br /> T <br /> R INSURER Adreini Company & Workman ' s Comp. WORK.COMP.M 1312649-93 <br /> A <br /> C FIRE DISTRICT Tracy PERMIT M N/A <br /> { PHONE M 510 846-3188 <br /> 0 LABORATORY NAME CKY Environmental/S arger Tech . _ <br /> R <br /> SAMPLING FIRM Wright Environmental PHONE M 2p9 833-0758 <br /> 111111111111111111111111111111 <br /> �pN IDM TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DAIE US S 1 p 0 <br /> 39. 2S 1 , 000 �1 DiesL l f l(,1 �96 - <br /> 1 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39-_- <br /> 39- <br /> P <br /> 9- <br /> 3939- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTR NT WITH CONDITIONS) C <br /> N PLAN REVIEWERS NAME DATE <br /> j- IIIIIIIIIIIIIIilllll 11111 <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: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECONS <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 CALIF IA." <br /> 1f , <br /> APPLICANT'S SIGNATURE: TITLE 1I ' F DATE I Z l <br /> * Old Transportation Facility <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />