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F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />SAN JOAQUIN COUNTY 'PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERI IIT <br />THE PERIT FORTANCE <br />EXPIRESM90 ERMANENT/TEMPORARY DOONOTBWRITTEMINTIN PLACE ANY SHADEDOF UNDERGROUND AREAS. INDICATEAPERMOITSTYPESSTORAGE TANK <br />BELOW: <br />x <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # CAL 000041551 PROJECT CONTACT & TELEPHONE # BARRY 1I• NIC"OLSON <br />FACILITY NAME PORT OF STOCKTON PHONE # 209-946-0246 <br />ADDRESS 2201 WEST tiGASHINGTON STRII�T, STOCri"`I' N, CA 95203 � :..z 7Z`13 <br />CRoss srREEr SL.'E A�1TAC#� SITE I�ZAPS FOR EACH TANS (4) <br />OWNER/OPERATORPORT OI ST©CKTON <br />PHONE # <br />209-946-0246 <br />C CONTRACTOR NAME JIINI THOB E OIL INC, PHONE # 2O�__CS_C1�� <br />0 r CA LIC # 405�i90 CLASS A B I <br />N CONTRACTOR ADDRESS351 lNoR,11i BLCI,LIAN ROAD, LORI, CA <br />TWORK.CCMP.# 1095135-98 <br />R INSURER Gld4STAR/blI�I-U' Z INSLR NCE <br />A PERMIT # G14 APPROVAL <br />C I FIRE DISTRICT CIIy OF STOCKTON <br />TCOUNTY SAN JOAQUIN PHONE # 200-042-0181 <br />0 LABORATORY NAME 'Ef$, -R'ecirrion EnYim-71C,4% <br />R PHONE # same as above <br />SAMPLING FIRM same as above <br />Illlllllllilliil!{lllllll{till �p C EM[ AIS17 TORED CURRENTLY/PREVIOUSLY liA7(3 T I & <br />TANK ID # 2 �0-100 N Ai� aSS 1111 Li U <br />39 T c) ;O�—L1�J09s— <br />T 39- 5 7- 10 0-0 _I <br />,.L' 0� <br />A 39- Lai — 2 <br />N 39 <br />K 3 - <br />39- <br />39-� <br />I1{ltl{1{Il{!1{11111{1111!{tll lllltI'll Fill ltllll lllllllll{tll t{llllllllllllllllllllllflll1111l1{{Ill tll{!It!{{1{Illllllll <br />P DISAPPROVED <br />L i APPROVED APPROVED WITH CONDITION(S) <br />A (SEE C ITIONS BELOW AND/OR ON ATTACHMENT) <br />N DATE <br />PLAN REVIEWER'S NAME_,l <br />llllllllllllll{II11l1l11lllllllllll{111lllllllllllllll{!ll{llllilllllllllllllillllllllllllll!llflllllllllllll{lllllllllllllll <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CCUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAOUIN 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 />"IBCERTIFYY THATEINSTHECOMPENSATION <br />PERF PERFORMANCELAWS <br />THEWORKFORAWHICHOTHISCPERMITHISIIISSUED,I G OR SHALLCEMPLOYSIGNATURE <br />PERSONS SUBJECTCERTIFIES <br />TO WORKER'S <br />COMPENSATION LAWS OF CALIFOINIA_" I / I / ENVIRONI451MA-L <br />APPLICANT'S SIGNATURE: <br />TITLE SPECIALIST <br />DATE <br />CONDITIONS}: f . 5- � -77') <br />irc 4r"Vo" cr", <br />1.-� y <br />0,� <br />EH 23 046 (Revised 9/11/96) � � u Page 3 <br />