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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> UPLiCA11ON FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IM PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THiS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE 1N ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE MCAC 000 83656 j PROJECT CONTACT = TELEPHONE David Barney (209)983-6565 <br /> A FACILITY NAM�.OIICI'ete �nC. PHONE 10 <br /> (209)983-6573 <br /> ADDRESS 749 S. Stanislaus St. Stockton CA 95206 <br /> Lt CROSS STREET <br /> Hazleton j <br /> T� OWNER/OPERATOR PHONE / <br /> T Concrete Inc. (209)983-9865 <br /> CONTRACTOR NAME Jin, Thorpe 011, Inc. 'PHONE 0 (209)462-4581 <br /> .1 CONTRACTOR ADDRE"351 N Beckman i1d. 'P.O.Bx. 357 CA LiC R 495 9 CLASS <br /> A. iN5U4ER f ir•esmans Fund/ Pacific :�.I nsur. Co. , LID WORK.cOFIP.0 State Comp. ns. U d <br /> G' FIRE DISTRICT City' 01- Stockton PERMIT 'On a <br /> pprovai <br /> of plan. <br /> 01 LABORATORY NAME PHONE ! <br /> A" GpaAng1ytjrn1 (20672-090i <br /> SAHPLIRO FiRMI PHONE 0 <br /> I !!1111 II1�1111!lIiI11 i <br /> TAN I TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- L1K <br /> T 39• gallons- diPGPI P11pi <br /> N39- ' <br /> K� 39- <br /> 39• <br /> i39 <br /> Plii1tI11ITTTTT11TTiTiTiiTTT t1�liiliTTTIliT11TTTiTTITiTTTT fTiTTTTTIITIIIiiiTillTTITiTTTTIl1T1TT1T <br /> Gr APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED f <br /> I. �SEE ATTACHMENT WITH CONDITIONS) <br /> I� PLAN REVIEWERS NAME DATE p� <br /> �Ti� Til-I�I��1 V I I I IfTiiTii�I�TT <br /> iLPLICAUT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOU1N COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> H JOAOUIR COUNTY PUBLIC HEALTH SERVICES. OMER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> E PERFOR14ANCE OF THE UORK FOR WHICH THiS PERMIT 12 ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATiOX LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: � <br /> ICERTIFY THAT 1N THE PERFORMANCE F THE FOR [CH THIS PERMIT 19 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> mENSATION LAWS OF CALIFORNi i <br /> APPLICANT'S SIGNATURE: TITLE COI1traCtQC DATE 1/13/94 <br /> i <br /> E}�'.3 046 (Revleed 7/10/92) Page 3 <br />