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F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDCUS 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 />XXX REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # CAC001024176 I PROJECT CONTACT & TELEPHONE # <br />FACILITY NAME Saddle City Chevron - Station # 90302 <br />ADDRESS 6241 W Paddock Place - Lodi, Ca 95242-9500 <br />I CROSS STREET Thorton Road <br />Cecil Dillon <br />PHONE # 209) 334-6613 <br />OWNER/OPERATOR <br />PHONE # <br />Flag City L.P., A <br />Cal LTD Partnership <br />(209) 334-0975 <br />CONTRACTOR NAME <br />Ramcon Engineering <br />& Environmental Contractin <br />PHONE # <br />916 372-7535 <br />CONTRACTOR ADDRESS 3751 Commerce Dr <br />- W. Sac CA LIC # 510034 <br />CLASS A-Haz <br />INSURER Wright <br />& Kimbrou h <br />WORK.CCMP.# PC942941 <br />FIRE DISTRICT <br />San Joaauin Countv <br />Fire <br />PERMIT # <br />0 1 LABORATORY NAME Western Environmental Science & Technology PHONE # (916) 753-9500 <br />R <br />SA14PLING FIRMillifillwes nvironmental Science & Technology PHONE # (916) 753-9500 <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br />39- <br />T 39- 17 nnn RP nlarfTTn1Parlerl 1993 <br />A 39- 1 7 -nnn -R j1 ar/jjnI Par1Pr1 1 (M <br />N 39- 1 19,non Praminm TTnleBdpd 1983 <br />K 39- 4 19r(lnn PrPmiiim TTp1padeej 19R <br />39- 17y(LM TIiPCP1 19Ri <br />39- <br />P <br />L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CCUN'fY 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, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S C'UNPENSATICN LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLC"WING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />CCMPENSATICN LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLEOwners/A ent g DATE �)-I/ <br />"EH 23 046 (Revised 7,10/92) <br />Page 3 <br />