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1 <br /> 1111111t PAYMENT <br /> ENVIRONMENTAL HEALTH DIV1410M ,.CINE P <br /> APPLICATION FOR RRDeRGROUIRD TANK CLOSURE PERMIT OCT 2 9 ^^^� <br /> A OE )GItJt4TiT f S <br /> APPtICATION too PERMANENt/IEMPORART CLOSURE OR ABANDONMENT IN PUCE OF UNDERGROUND SHADED REAS.HAZARIND SU44AM M ,�I Tu.CCpU+IV!SI^' <br /> tiV1RO�dNI 'EIAE,LtlQ11R}� <br /> IMI! PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DAZE. DO NOT WRITE IN ANY SHADED AREAS. INDICIII�-flflM <br /> REMOVAL _ -_ TEMPORARY CLOSURE __ <br /> ABANOONIIENT IN PLACE <br /> pROJECt CONTACT A TELEPHONE N Jim Thorpe Oil Inc. 8- <br /> EPA SITE N CAC 000649624 <br /> PHONE N (209)835-8790 <br /> I FACILITY NAME Caldron's General Store <br /> A <br /> r, ADDRESS 12750 W. Byron Rd. Tracy, Ca. 95376 <br /> R <br /> L CROSS STREET Lammers Rd. <br /> 1 PHONE N <br /> 1 DWNER/O•ERATO (209)835-8790 <br /> Y Alfred F. Caldron <br /> PHONE N 209)366-617r) <br /> C COIINACIOI NAME Jim Thor re 011 Inc. / U.U.A, Rich-Hart Const. <br /> D ec nd CA LIC N4 cuss <br /> N rnRIRACTOR ADDRESS Po. Ux. 357 Lodi Cal. 95241-035 56 A B Haz. <br /> r WORK.CDMP.N 1095135-90 <br /> R NunlRpe Fir•emans 1'und / Admiral <br /> PERMIT NFire permit will be <br /> c rIRE DISTRICT Tracy d II�su e--1PPr= <br /> PHONE N <br /> n UROIIAIORT NAME F.C.L. Environmental (209)94? 0181 <br /> R PHONE N Same as above <br /> SARPIIND FIRM Same as above <br /> IIIIIIIIIiIIIIIIIIIII'I'I II III TANK 512E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK ID N ,Tari L:aC <br /> I9 2 um 000 gal. PremiUnlea <br /> 1 I9 — 2,000 gal. Regular Unleaded Gas <br /> A 79-- <br /> # 39- <br /> K 70- <br /> J9- <br /> 79- <br /> - IIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIII <br /> 0 <br /> L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATtACHMERi MIT" CONDITIONS) <br /> GATE <br /> N pt AN REVIEWERS NAMF- _ <br /> — IIIIIIIIIIIIIIIIIIII'IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIfIIIIIIIIIIIIIIIIIIIIIII'll"'IIIIII <br /> APPLICANT RIUSI PERFORM ALL HONK IN ACCORDANCE NIT# SAN JOAouIN CORNY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS Of <br /> OUIN COMMIT PUBLIC REALIN SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "i CESTIFY THAT in <br /> SAN JOA <br /> SNE PERFORMANCE OF INE TAR% FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SIIBIECT 10 NDRKER'! COMPENSATION LAWS OF CALIFORNIA." CONIRAC1011'S HIRING OR SUBGOITRACI IMO SIGNATURE CERTIFIES THE FOLLOWING: <br /> ',l CERTIFY THAI IN THE PERFORMANCE Of INE WORK FOR WHICH NNIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS s(UBJECT t0 LARKERIS <br /> tOPENSAIION LAWS 01 CALIFORNIA.", <br /> TITLE C tra tpr DATE 10/29/91 <br /> APPLICANt'S SIGNATURE: 4-"- <br /> PROe 1 <br /> ER 23 066 (Rev 2/0/91) It Co <br /> �./ <br />