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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> "HIS PERMIT FOR PERMANET7-TTEMFORAR�CLOSURE OR AEANDONMENT IN PLACE OF UNCERGROUND HAZAROCUS SUSS-ANCES <br /> STORAGE TANKS)EkPiRES 90 MAYS FROM THE APPROVAL CAT E. DC NOT+NRI:E IN ANY SHADED AREAS. INDICATE_FiP+Mr TYQE <br /> E REMOVAL Cl TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EF:A--`.LI--yNAM!E <br /> M PROJECT CONTACT ROn ?HON 2O9 - <br /> T e I PHONE I <br /> IACCR>as The r ht of way ad 'acen to 3 <br /> tonktnn CRCSSSTREB" Miner St . PHONE?w - <br /> OWN�OPERA70R The Ci <br /> CONTRACTORINFORMATiON <br /> CONTRACTOR NAME Jim Thor e I alrz <br /> PHONE <br /> CCNTRAC-OR ACCRESS P.O. B 7 CALICO CLASS <br /> !NSURER GenStar/Golden E '�vGRKERCCMPi/ <br /> F:RE D;S-R1CT e 1 y Of Stockton PERMITS U Ori a royal <br /> LAEiCRATORY'NAME GeoAnal tical Labs CCLNtt St n PHONEn 209 0 <br /> '3A.:'PLiNG I M GeoAnal t ' oy NE S <br /> TANK INFORMATICN <br /> -ANK!D# TPNK SIZE TANK CCNTE`M(PRESENT$ PAS7 DATE iNSTALLED <br /> 3g 500 le d a iinknnwn <br /> lag 500 leaded gasoline unknown <br /> g y- <br /> 13g" I <br /> 39- <br /> 30. <br /> APPUCANT MUST PERFCW.I ALL TJORK:N ACCORDANCE i'NTH SAN JOAQUIN:OUNTY CROINPNCFS,STA-E LAV"S FEO ERAL LAWS..4N0 RULES ANO <br /> REvUL1'104S OF SAN JOAQUIN CCUNT`.'PUBLIC HEALTH SERVICES. Ch-AEP.OR UCENSEC AGENTS SIGNATI;RE CERTIFIES THE?CL_OWING; " <br /> CERTIFY THAT IN THE PEPFCR}dMICE DF-HE WORK FOP LLHICH THIS PIRW S 3SUW I SHALL NOT E,V,PLOY ANY PERSCN IN SUCH A MANNER AS <br /> To=ECCME SUBJECT TO WORKER'S COMPS QOV L:.OFC H WORK FCR�CH THIS PERMIT IS BSUEOOR u;$SAN L EMPLO P PSONe SUS�TIE, <br /> -HBFCLLMINO: •I CERTIiY THAT IN -I 09 <br /> I-lCPXSR'S COMPSNSATICN LAW- <br /> Contractor 4/16/01 <br /> APPLCANTS SIGNATU L1GTL£ DATE <br /> ❑ APPROVED PPROVED WITH CONDiTION(S) Cl DISAPPROVED <br /> (SF.F CONCI7CNS 93_OY4 ANCIC R CN ATTACHMENT; <br /> yIII <br /> PLAN II 1I' � OA?E x-17-n 1 <br /> RE'AE'.VER'3 NAME <br /> ANY Cr,(A-ONS FROM 74I3 AP°LICATICN MUST 3CO'NMD+T ONS: <br /> yC FOR APPROVAL PRIOR TO CO UIENCING <br /> --.;�� rRE`IISED ntrt;l99; <br /> Rip 3 <br />