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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 /> REMOVAL _ TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # CAC000840664 PROJECT CONTACT & TELEPHONE # JIM HOBLITZELL (209) 463 7108 <br /> F FACILITY NAME NSA PHONE 1(209) 948 9003 <br /> A <br /> C ADDRESS 3507 STEVENSON AVENUE, STOCKTON CALIFORNIA <br /> I <br /> L CROSS STREET NEWTON <br /> T OWNER/OPERATOR WILLIAM VALENCIA PHONE # <br /> Y (209) 948 9003 <br /> C CONTRACTOR NAME PHONE # <br /> 0 <br /> (2nq) 463 7108 <br /> N CONTRACTOR ADDRESS PDX CA LIC # CLASS it All <br /> WITH HA7T <br /> R INSURER WORK.CCMP.# <br /> A ON FTI F <br /> C FIRE DISTRICTPERMIT # <br /> T <br /> 0 LABORATORY NAME PHONE # (916) 362 8947 <br /> R <br /> SAMPLING FIRM 6PARGER IECHNOLOGY PHONE # <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- — O1 GA,rni Tnir_ 1144in41 <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 1111111 wl <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAWIN 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, 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.-,a� <br /> APPLICANT'S SIGNATURE: - `-7 I TITLE DATE <br /> E LITZ V.P. & ENvIRONMENTAL MANAGER <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />