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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 /> XX REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # CAC000760344 PROJECT CONTACT 8 TELEPHONE #DOUG MARSTALL,MGR. (209) 832 8400 <br /> F FACILITY NAME PHONE #(510)674 8770 <br /> A PIEDMONT LUMRFR CO- <br /> C ADDRESS 7777 WEST ELEVENTH STREET, TRACY, CALIFORNIA 95376 <br /> 1 <br /> L CROSS STREET CHRISMAN <br /> 1 <br /> T OWNER/OPERATOR PIEDMONT LUMBER CO., OWNER PHONE # (510) 674 8770 <br /> Y <br /> C CONTRACTOR NAME JAMES J. HOBLITZELL PHONE # (209) 943 7793 <br /> D P.O. BOX 30331 STOCKTON CA 95213 <br /> N CONTRACTOR ADDRESS > > CA LIC # 365234class "A"HAZ <br /> T <br /> R INSURER NA WORK.COMP.# EXEMPT <br /> A <br /> C FIRE DISTRICTY RURAL PERMIT # <br /> 0 LABORATORY NAME MCCAMPBELL ANALYTICAL PHONE # (510) 798 1620 <br /> R <br /> SAMPLING FIRM EPIGENE INTERNATIONAL PHONE # (510) 791 1986 <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIII <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39 350 GAL. AIJPRZ X. PREVIOUSLY. GASOLINE UNKNOWN <br /> - <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> II1111111111111111 III IIII Illlllillllllllllllll 111 II 1 1 1 1 1 1111 I II11111111 I II 11 I I I IIII <br /> P <br /> L _ APPROVED X APPROVED WITH CONDITION(S) DISAPPROVED <br /> A SEE TACHM ITH CONDITIONS) R/ <br /> N PLAN REVIEWERS NAME I DATE <br /> 11111111111111111111 IIII i <br /> APPLICANT MUST PERFORM ALL IN ACCORD E TH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN CWNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I 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 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 /> CONTRACTOR / / nnkk A <br /> X W(XMXK SIGNATURE: TITLE (�14c G �U r P DATE L <br /> EH 23 046 (Revised 4/26/94) Page 3 <br />