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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> k <br /> TANK <br /> APPLICATION FOR <br /> xP R ANCNTDATMPRARRYOM TNEAPROVALADATE. DOTNOT MITE IN IV PLACE OF NYESHADDEDDAREAS. <br /> INDICATE OUS TPERMIT TTPEEBELOWS <br /> THIS PERMIT 90 <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> • �r <br /> EPA SITE CAC ��� Q416 PROJECT CONTACT S TELEPHONE 0 Aldo Fre airo 20 4b-0246 <br /> PHONE S 20 46-0246 <br /> r: FACILII' NAME The Port of Stockton <br /> - <br /> c ADbRESS 220 W. Washin ton St Road B Stockton CA <br /> S CROSS STREETR/OPERATOR NavyDr. " <br /> PHONE 0 <br /> T OWNE (209)946.:-0246 <br /> ;_ The Port of Stockton �� <br /> PHONE R 20 $_ <br /> CONTRACTOR MAKE Jim Thorpe Oil Inc./Rich-Mart Construction <br /> D u t[c <br /> 4 56 cuss A B Haz. <br /> N CONTRACTOR ADDRESS 351 N Beckman Rd Lodi Ca. 5240 <br /> - R WORx.COMP.� _ <br /> INSURER Firemans Fund/ New En Land <br /> 90 <br /> PERMIT To be-arrancred <br /> C FIRE DISTRICT <br /> i LABORATORY RAKE GeoAnal�tical 1. PHONE � 20 Laboratories <br /> L PHONE # 0 - <br /> SAMPLING FIRM Same as above <br /> Ililillllllllillllillllllllli TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK ID <br /> 39- 6Q() al l nng unle --asolrri Lie <br /> �i 39- . <br /> A 39- <br /> L39- �. <br /> 39- <br /> 39- <br /> 39- <br /> t <br /> lilt ` <br /> APPROVED IT[ DISAPPROVED <br /> r` APPR DATE <br /> NPLAN REVIEWERS NAME 11111 <br /> T. Illllllll1111111i111 <br /> APPLICANT MUST PERFORM ALL WORK IN AC DANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES- OWNER OR LICENSED AGENT'S SIGNATURE CERTIF[E5 THE FOLLOWING: *1 CERTIFY THAT 1N <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.." THISCPRMIToS HISIISSUED, [NG OR SHALLCEMPLOY TING IPERSONS SUBJECTGNATURE £10TNWORKER'SW NG. <br /> TRA <br /> ,,"I CERTIFY THAT IN THE PERFORM E WORK FOR <br /> COMPENSATION .LAWS OF CALIFORNI . <br /> APPLICANT'S SIGNATURE: <br /> TITLE DATE <br /> L <br /> I' r- <br /> Page3 <br /> EH 23 046 (Rtvised 7/10/92) j <br /> I <br />