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SAN `AQUIN COUNTY PUBLIC HEAL' SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />EIREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />TANK INFORMATION <br />FACILITY INFORMATION <br />TANK SIZE TANK CONTENTS PRESENT & PAS DATE INSTALLED <br />EPASITE#CAC <br />002572159 PROJECTCONTACT Fred Miner <br />PHONE# 209) 946-0233 <br />FACILITYNAME <br />Diesel P <br />PHONE# 946-0233 <br />ADDRESS <br />2900 E. Fremont St., Stockton CA 95205 <br />S).<IC '^.- <br />Ge0dndl tl Cdl Laboratories <br />CROSSSTREET <br />Shasta <br />SAMPLINGFIRM <br />OWNER OPERATOR Tese I Performance, Inc. <br />PHONE# 209 946-0233 <br />TANK INFORMATION <br />CONTRACTOR INFORMATION <br />TANK SIZE TANK CONTENTS PRESENT & PAS DATE INSTALLED <br />CONTRACTOR NAME Jim <br />fhorpe Oil, Inc. <br />I PHONE# <br />209 368- 17 <br />CONTRACTORADORESS - <br />INSURERAInerican Internat'1 S ec.LlneS <br />CALK#, _¢ 569 <br />WORKERCOMP# State Puna. <br />CLASS A B .HAZ <br />1671173-02 <br />FIRE DISTRICT <br />LABORATORY NAM <br />S).<IC '^.- <br />Ge0dndl tl Cdl Laboratories <br />PERMIT# U on ADDroval <br />NTv `Stan. ^�(2091,- <br />SAMPLINGFIRM <br />ebdnd tlCddbOr Or S <br />IPHONE # same dS d Ve . <br />TANK INFORMATION <br />TANK 10 # <br />TANK SIZE TANK CONTENTS PRESENT & PAS DATE INSTALLED <br />39- <br />900? unleaded gasoline Unknown <br />39- <br />900? unleaded gasoline I In <br />39- <br />39- <br />39- <br />39 - <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS, FEDERAL LAWS. AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br />TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS FO <br />APPLICANTS SIGNATURE <br />TITLE Contractor DATE 11/19 03 <br />❑ APPROVED UTtPROVED WITH CONDITIONS) ❑ DISAPPROVED <br />(SEE CONDITIONS BELOW ANOJOR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME DATEZ� <br />ANY DEVIATIONS F M THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />EH 23 046 (REVISED 08113199) Page 3 <br />