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PIPING ONLY <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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOWt <br /> X REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # PROJECT CONTACT $ TELEPHONE # c C)enS eln <br /> CAL 000032494 Tait & Associates (510) 680-6800 <br /> F FACILITY NAME ARCD Facilit 5569 PxouE—0—C209) 474-9343 <br /> A <br /> aoDREss <br /> 1 3518 Fast Hallmler Lane Stockton CA 95210 <br /> I <br /> L CROSS STREET <br /> i Holman Road <br /> T OWNER/OPERATOR PHONE If <br /> Y ARCO Products Co AT N: Environ. Health & Safety <br /> C CONTRACTOR NAMEAmerican Construction PHONE Al <br /> 0 447-2484 <br /> N CONTRACTOR ADDRESS 567 Exchange Ct. CA LIC # ,702214 CLASS A <br /> T <br /> R INSURER State Can nation Ins. Fund. CA WORK.COMP.a <br /> A 571-1486-94 <br /> C FIRE DISTRICT Stockton F.D. PERMIT # <br /> T sEONoi,4 ,4NAJ,)0 7 j: Q &$61CO JyrNTO 2 <br /> 0 LABORATORY NAME CC••�� " PHONE a 910 9 • M <br /> R SAMPLING FIRM G/�F�•�� �`JSOr/� s PHONE # 91Q+ 2a-$30/ <br /> TANK ID a TANK 512E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 233 }- O I <br /> T 39- Plpina On y�2.ccx� Oc ane Gaso ine S�Rme—�95 <br /> A 39- Pio r(x)0 mane Gasoline Stemmer F95 ._ <br /> K 39- Piping oniv i2Z pock- 87 Octane Gaso ine Summer '95 <br /> 39- <br /> 39- <br /> (ITTT [TI ITi MTrFUTTT T TI T <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ( EE AT ACHM N I1H CONDITIONS) Q _��_9 <br /> R PLAN REVIEWERS NAME DATE O l <br /> I I I I I f l l l l l l l l l l l l l l illlrffffrmmlI 1111111111111 <br /> APPLICANT MUST PERFORM All WO IN ACCOR I WI 11 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 WORK 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 WORK FOR WHICH THIS PER141T IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." ((�� <br /> APPLICANT'S SIGNATURE: ]�w. . lir=�\ � TITLE 2GlA-- >✓ DATE 5/23/95 <br /> CONOITIoFOS ' / <br /> 1, 7b-v& �T"p'i� Ul�osrho� Tso �J�, d t�, be ccsn,(�lc>lcG� aLlt� scalpm�C�cCY <br /> rta ^li,�s c.� w�lh �30 dos-.�sC1 <br /> Tc�+nl <br /> CLnaz <br /> 1L� edPeT- - TPH—Cr, 3T�)C CcctGl <br /> 3, Vcr I CP � Leil#h 3= 0c t�cvcwtto�. <br /> EH 23 046 <br /> (Revised 4/26/94) Page 3 <br /> LL ( ZCSL. /JI"Lcs�✓(.� J <br /> ✓v1'tuz,* GCS <br />