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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERAMENT/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 /> X REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE B CAD 043274380 PROJECT CONTACT S 1E1EPIUME B Todd Teresi (209)368-2472 <br /> I FACILITY NAME Teresi Trucking PHONE / (209)368-2472 <br /> A <br /> C ADDRESS 900 1/2 E. Victor Rd. Lodi, CA 95240 <br /> 1 <br /> I. CROSS STREET Beckman Rd. <br /> 1 <br /> 1 O HER/OPERATOR PHONE <br /> Y Same as above (209)368-2472 <br /> C CONTRACTOR NAME J1111 '1'11pr•pe Oil, 1110. PHONE (209)462-4561 <br /> 0 <br /> N CONTRACTOR ADDREs$351 N Beckman Rd. P.O.N. 35- CA LIC B q �6 CLASS <br /> Ia el?O�Hip. <br /> 4rns.-Fui d <br /> R INSURER Piresmans Fund/ Pacific Insur. Co. , LTD WORK•EOMP•R1095 1 Irl. <br /> A <br /> C FIRE DlslRlcr The City of Lodi PERMIT BOP approval of plan <br /> I <br /> 0 LABORAIORY NAME GeoAnalytical Laboratories PHONE 1 (209)572-0900 <br /> R — <br /> SAIIPI IN(; I IRM Same as above PHONE B (209)572-0900 <br /> — 1111111111111111111/1111111111 AJ� 1ZE �(A 0R <br /> 79- /7TANK <br /> 7�ON 1 ,DOTUNgaiTon CWE"VaLstes 8TlcuRRENIIY/PREVIOI15lY DA�7ZST INSTALLED <br /> I 39- 1 <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> liiinnnnnnnnnnnnn mm�rrnnnnnmm�nrrrr rrrnnmm�mnnnrnnnrrrrrrrrr nnnrmmnnnn <br /> P <br /> ( X APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A SEE ATTACHMENT WIT" CONDITIONS) <br /> N PIAN REVIEWERS NAME DATE Z� 9 <br /> - IIIIIIIIIIIIIIIIIIIIIrlrlllrllllrl Illl mi11rI1111TII11rIIIlIr11r11IrI1rII1tIIIIlrrtllrrllllllllrt IIr Irrllrrrrltttrrrrrll <br /> APPLICANT MIST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUTN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS Of <br /> SAN JOADUIR COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO$ •1 CERTIFY THAI 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 WIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLIOJINO: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE_"K FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT 10 WORKER'S <br /> COMPENSATION LAWS OF CALIfORN A " I <br /> APPLICANT'S SIGNATURE$ "v-O-� 'L-.-G_---- TITLE ConLracLor DATE 4/18/94 <br /> EM 21 046 (Revl Sed 7/10/92) Page 3 <br />