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SAX JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIN'IEN7AL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERNIIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL AAT . 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE(3ELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PL gE <br /> EPA SITE /1�/r ~fZ�Q71 PROJEC" CONTACT S TELEPHONE t Bill Li /le 467-1 006 <br /> F I FACILITY NAME Martini Automotive CNE-0 462-8696 <br /> A E <br /> C ADDRESS 4032 North Eldoado Street <br /> L CROSS STREET Churchill } � <br /> I ! <br /> T CWNER/CP=RATOR Mike; Ma inl PHONE # 46208696 <br /> Y ! <br /> C <br /> C:NTRACTCR NAME Advanced Geo Environmental PHONE x 467-1006 <br /> N C,NTRACTCR ADDRESS 4005 North Wilson Way LIC # 680227 I. CLASS A az <br /> T <br /> R INSURER St. Paul Fire and Marine/ Desi-§' ' of. INS WORK.CCMP.* - <br /> 1 A <br /> C F:RE DISTRICT Stockton PERMIT Y <br /> T <br /> 0 i LABORATORY NAME MC Campbell I COUNTY C Vtra Costs PHONE -.# 925798- 1 620 <br /> R ue Henderson egls ere If 50.17, <br /> SAMPLING FIRM . I PHONE # 467-1006 <br /> 1111111tllllllllllllll[IIllI1t <br /> TANK 10 s TANK SIZE; / CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br /> 39- , 1 <br /> T 39- u 7 pn suspeC waste oil <br /> � <br /> A 39- ! <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> - 111�111tllllltlillililllllllllllll1111l1111'IlEllllllllll111lllllllillll111111 <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N y <br /> PLAN REVIEWER'S NAME DATE <br /> llllllll111tlllllIIIIIIlll1/INCORDANCE <br /> till!111111�111111llllltlllllllllllllllillllll[!l111`lltllllllll1.111lIIIIIIIIIIIIIIt1111 <br /> APPLICANT MUST PERFORM ALL WOCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEAS. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE ,FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN 'SUCH A MANNER AS TO BECOMESU84ECT TC WCRKER'S COMPENSATCALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:' <br /> "I CERTIFY THAT IN THE PERFORE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OFCALIFORN <br /> APPLICANT'S SIGNATURE: \,/1��C/ TITLE �7 / 41 <br /> DATE r <br /> i Ir` <br /> CONDITION(S): <br /> f, - <br /> 412kr&_i.-µ-4-. <br /> kto CA, <br /> EH 23 046 (Revised 9/11/96 Page 3 <br />