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FSAN JOAQUIN COUNTY PUBLICI HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> r- APPLICATION FOR UNDERGROUND STORI GE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE Of UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL HATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # <br /> CAC PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME Tri. Star Homes, LLC PHONE # (510)838-1460 <br /> A <br /> C ADDRESS 1325 N. Corral. Hallow Rd. , Tracy CA <br /> I <br /> L CROSS STREET Grant Line Rd. <br /> 1 PHONE # <br /> T OWNER/OPERATOR Tri Star Homes (510)838-1460 <br /> Y <br /> r C CONTRACTOR NAME JiITI Thorpe Oil, 111c. PHONE N(209)368-6175 <br /> 9_ N CONTRACTOR ADDRESS 351 N. Beckman Rd./P.0. BX 357 cA LIc # 495699 CLASS.',,.A,B,HAZ <br /> T <br /> R INSURER Firemaris Fund/General Star WORK.COMP.# 1095135 <br /> '; A PERMIT # upon approval <br /> C FIRE DISTRICT The City of Tracy <br /> T COUNTY Sari JoagUiil PHONE # <br /> r 0 LABORATORY NAME Geokiaylytical (209)572-0900 <br /> R SAMPLING FIRM GeoAnal-ytical Laboratories PHONE # (209)572-0900 <br /> llllllllllTANK lllllll��lllll TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK ID # uk <br /> r 39_ 300 allons ld asolirle <br /> r 39 I :�l~ <br /> A 39- <br /> N 39- <br /> 39- <br /> c_= 39- <br /> P 1111 <br /> 1111 fffffffffluffi <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONQITi NS BELOW AND/OR ON ATTACHMENT) <br /> HDATE <br /> PLAN REVIEWER'S NAME <br /> II11lltllllllllillililllll llllil ill illll[lllllllll111111111illlllllllllilllllllllllllllllllllllllllllllll11111111i <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> r_ 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 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <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 /> COMPENSATION LAWS OF CALIFORNIA." <br /> r <br /> . . _ (--� TITLE Contractor DATE 5/19/97 <br /> APPLICANT'S SIGNATURE: <br /> F` CONDITION(S): <br /> f <br /> F <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />