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tau <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UR 22 1991 <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> AL <br /> £NT TEMPORARY CLOSURE OR ABANDONMENT IN PLACE Of UNDERGROUND HAZARDOUS SUBSTAHCE � � CEf <br /> APPLICATION FOR PERMAN / �BBi�`�LOOWW""''�� <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. Do NOT WRITE IN ANY SHADED AREAS. INDICATE PERMf1 <br /> xX REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> (209) 838-3507 <br /> i` PROJECT WNTACI 6 TELEPHONE # JO <br /> EPA SITE 0CAC 0005$34 2 g <br /> 41,11 <br /> PHONE # ! <br />' F FACILITY NAME Van Buskirk Golf Course # <br /> IA <br />{ c ADDRESS 1740 Houston Ave.Stockton Calif. <br /> k. 1 7 <br /> L CROSS STREET <br /> 1 PHONE # (209) 944-8438 <br /> T OWNER/OPERATOR City Of Stockton <br /> 1.465 Lincoln } <br />( PHONE # <br /> C CONTRACTOR NAME Jim Thor e Oil Inc. / D.B.A. Rich-Mart Const. 20tA <br /> -61 <br /> 51 N. Beckman fid CA LIC # tL <br /> N CONTRACTOR ADDRESS Po. Bx. 357 Lodi Cal. 95241-035 4 56 /B Haz. <br /> 2 7 WORK.COMP.# OIl Fi <br /> R INSURER On File <br /> .i <br /> j A PERMIT # <br /> C FIRE DISTRICT -City of Stockton <br />' T p lied Analytical Environmental Labratories PHONE <br /> 0 LABORATORY NAM£'p Y <br /> St gilit. jn Er- ant Cali 45 923� <br /> R PHONE # <br /> SAMPLING FIRM Water work Corp. (209) ;838-3507 <br /> lllllllllllllllllllillllllllll <br />' TANK D # xF550 <br /> SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY'Y' OATS USF INSTALLED <br /> 39 % 6 <br /> C! al. Diesel Fuel <br /> T 39- l <br /> A 39- 1 <br /> N 39- <br /> K 39- <br /> 39- 1 <br /> 39- <br /> III 111111111111111111111111111 111!111!1!!11 I1111111111l111111111111111111111111111 I!l1111!!1111111lI!!1 <br /> „ L APPROVED �. APPROVED WITH CONDITIONS) <br /> A (SEE ATT CHME WITH CONDIT[ S) '� r <br /> DATE i <br /> x N PLAN REVIEWERS NAME <br />� 11111 <br /> !ll 11 Ili li ll 111 fl 111 ll 111 11 11 l ll 11 111 ll 11 l l l ll l l l 11 l ll 11 l 11 11 111 it l l 11 ll l 11 111 ll l ll l l l l 111 01111111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAH JOADUIH COUNTY ORDINANCES, STATE LAWS, AND RULES'AND REGULATIONS OF <br />� SAN JOA4UIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING "! CERTIFY THAT IN <br /> �� <br /> [ SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, EC <br /> SUBJECT TO WORKER'S COMPENSATION LAWS Of CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERiIFlES THE FOLLOWING: <br /> OL <br /> S <br /> "! CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL EMPLOY PERSONS UBJECT TO WORKER'S <br /> COMPENSATION LAWS Of CALIFORNIA." <br /> TITLE Pres. DATE 4 1 <br /> APPLICANT'S SIGNATURE: <br /> Page <br /> `. EH 23 046 (Rev 2/8/91) ft <br />