Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> ANCE <br /> AGE <br /> ITY- <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND <br /> HAZARDOUS AREAS. INDICATEiPUMIT1TYPE BELOW.-. <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO N01 MUTE IN ANY SHADE u ;` „I <br /> —K REMOVAL _ _ TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE N CAC 000649624 PROJECT CONTACT R TELEPHONE S Jim Thorpe Oil Inc. 20 8- 1 <br /> PHONE N (209)835-8790 <br /> F FACILITY NAME Caldron's General Store <br /> A <br /> C ADDRESS 12750 W. Byron Rd. Tracy, Ca. 95376 <br /> I . <br /> L CROSS STREET Lammers Rd. <br /> I PHONE N <br /> T OWNER/OPERATOR (209)835-8790 <br /> Y Alfred F. Caldron <br /> PHONE M <br /> C CONTRACTOR NAME ,Jim Thor' e Oil Inc. / U.B.A. Rich-Mart Const. 20 68-6 <br /> 0 1 N. Beckman Rd CA LIC NCLASS <br /> N CONTRACTOR ADDRESS Po. Bx. 357 Lodi Cal. 95241-035 4 56 A B Haz. <br /> 1 WORK-COMP-1 10. 95135-90 <br /> R INSURER Fi.trematis Fund / Admiral -- <br /> A PERMIT N Fire permit will be <br /> C FIRE DISTRICT Tracy d-upoa-UPS <br /> T PHONE N <br /> 0 LABORATORY NAME F.G.L. Environmental (209)942-018 <br /> N Same as above <br /> SAMT`LINR FIRM Same as above . <br /> IIIIIIIIIIIIIIIIillillllllllll TANK SIZE CHEMIas <br /> CALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLEDI f J <br /> TANK 10 N ,` rl <br /> 2,000 dal. Premi Un <br /> T 39 y/�” �/- D3- 2,000 gal. Re ular Unleaded-La-s- <br /> A 39- <br /> N 39- <br /> 9 39- <br /> J9- <br /> 39- <br /> . - llllllllllllllllllllllllllllll 11111111111111111111111111111111 llllllllllillilililllilllllllllllllllll Ililllllilillllilllil <br /> P <br /> L 1� APPROVED APPROVED WITH CONDITION") DISAPPROVED <br /> _ <br /> A (SEE ATTACHMENT WI CONDITIONS))J ATE _ <br /> N PLAN REVIEWERS NAME II11111111111111111IIIillllIIIIIIIIIIIIHill <br /> illilillllllllllllllllllllillllll11111111111111111111111IIIIilllililllllll illll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN 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: Of 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 /> SUBJECT TO WORKER'S COMPENSATION <br /> AOWS F f THECWORK FORANHICNOTNISCPERMITHIRING <br /> 155UEDSUICSHALLCEHPLOTSIGNATURE <br /> PERSONS SUBJECTCERTIFIES <br /> TOTHE <br /> WORKERLOLIING: <br /> "1 CERTIFY THAI IN THE PERFORMANCE <br /> COMPENSATION LAWS Of CALIFORNIA." <br /> / TITLE S'nntr•_Ctpr DATE 10/7a/9J — <br /> APPLICANT'S SIGNATURE: <br /> EN 23 046 (Rev 2/8/91) ft Page 1 <br />