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ENVIRONMENTAL HEALTH DIVISION i! -PA Y)' <br /> i <br />� APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT "'�.>• <br /> � '' <br /> —.0�a <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARD OUS„SNB01S'IAbCE r$HMAgE,FACI4LTY, <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. IND[OATEN ERdI 1T PE' E TIlf;:!�. <br /> TY <br /> ` <br /> _ REMOVAL TEMPORARY CLOSURE _ ABANDONMENT IN PLACE <br /> EPA SITE # CAD982356941 PROJECT CONTACT & TELEPHONE #JIM BAILEY, (209) 464-7635 <br /> F FACILITY NAME HUSKY CRANE, INC. !' PHONE # <br /> A (209) 464-7635 <br /> C ADDRESS <br /> 1 2373 MARIPOSA ROAD STOCKTON CALIFORNIA 95205 <br /> L CROSS STREET <br /> I HIGHWAY 99 k <br /> T OWNER/OPERATOR f PHONE # <br /> Y WILLIAM D. JOHNS q (209) 464-7635 <br /> C CONTRACTOR NAME HUSKY CRANE, INC. PHONE # (209) 464-7635 <br /> N CONTRACTOR ADDRESS FP Al eie. J:A PC # CLASS <br /> T 2373 MARIPOSA ROAD ,,,; $63071 "A” <br /> -1 <br /> R INSURER CALIFORNIA COMPENSATION CCP Z R I WORK.COMP.# <br /> A W1600304 <br /> \''•i ��JL�n .. .jj <br /> C FIRE DISTRICT MONTEZUMA p?,�_!L rEn ,..� -1 r ,.� PERMIT # <br /> T <br /> 0 LABORATORY NAME <br /> R SEQUOIA ANALYTICAL LABORATORIES 'f PHONE # (415) 364-9600 <br /> SAMPLING FIRM FALCON ENERGY PHONE # (209) 463-7108 <br /> 11111 III II Iil 11111f1 it 11111111 <br /> TANK 10 # TANK 512E CHEMICALS ST- /PREVIOUSLY GATE UST INSTALLED <br /> T 39- 115 4f-Z OOo- r' GASOLINE U <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> III11111111111111111111111111111111111lIIIIII11111111111111111 illlllll1111HillHillI1IIIIIIillllllll il11111111111111111111 <br /> P / Y <br /> L _SL/ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATY MENT �Y CONDITIONS) 11 <br /> N PLAN REVIEWERS NAME /f.!} li DATE <br /> III II111111lI it 1111111111II ill 11 111 11 11 111!1!11 II 111111111 I III II III I!1111111 11111111111111111111 11 fll 11 II1111111111111 II 111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN 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: "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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." 1 <br /> 14 <br /> HUSKY CRANE, IN . <br /> ;I <br /> APPLICANT'S SIGNATURE: BY: J_ TITLE FINANCIAL MANAGER DATE 09/05/91 <br /> q <br /> u <br /> EH 23 046 (Rev 2/8/91) ft -- Page 3 �� <br />