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F <br />A <br />C <br />I <br />L <br />B <br />i <br />Y <br />C <br />0 <br />N <br />1 <br />R <br />A <br />C <br />T <br />0 <br />R <br />A 0 0 <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />moi« <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />THiS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE 10 ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE N CAC 00 C)q Lie PROJECT CONTAC <br />FACILITY NAMEWest Lane Fuels <br />ADDRESS 3300 West Lane Stockton, CA 95204 <br />CROSS STREET Alpine <br />OWNER/OPERATOR <br />Jay McIlrath <br />CONTRACTOR NAME Jiffs 'Thorpe Oil, Inc. <br />CONTRACTOR ADDRESS 351 N Beckman Rd. P .0 . Bx . 357 <br />INSURER Firesmans Fund/ Pacific Insur. Co., <br />FIRE DISTRICT <br />LABORATORY NAME GeoAnalytical . <br />SAMPLING FiRM Same as above <br />- 11111111111111111111111111111 <br />TANK ID TANK SIZE <br />T & TELEPHONE M Jay McIlrath <br />PHONE M <br />LTD <br />PHONE M <br />(209)462-8 <br />PHONE M ( onn % /.r- 7 <br />CA "C M 445699 i CLASS <br />WORK.COMP.0 inn -t: <br />l -icl' vill' a w" <br />PERMIT MOIL avvrova <br />PHONE 0(209)5720-0900 <br />PHONE 0(209)572-0900 <br />CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- 17 'S 'I —C)- 550pl 1 anS used Oil bink ewn <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />- Iii11TTTTT1tiTTT11TTTiTTTT tiiTTT1TTTTTTTTTT iTTTT TTT iTT TTTTTTT <br />P <br />L APPROVED APPROVED WITH CONDiTION(S) _ DISAPPROVED <br />A (SEE ATTACHNENT WI ONO T <br />H PLAN REVIEWERS NA14E DATE <br />- 1111111111111111111111T1T TTi 1 i1iTTTTT111111 T <br />APPLICANT MUST PERFORM ALL WORK iN ACCORDANCE 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 CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THiS PERMIT IS ISSUED, 1 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 PERFORMANE OF HE WORK FOR WHICH THiS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA.!"--Y/T <br />APPLICANT'S SIGNATURES <br />EH 23 046 (Revised 7/10/92) <br />Page 3 <br />TITLE Contractor DATE 3/6/94 <br />d <br />