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i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT �Jl <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAIARDOUS SUB�� N9E 4T7A0�ICILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICAT 061111 YP B OWS <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLAcENVI14N�M NT lC' T" <br /> PFRMEPA SITE N CAC 000601440 PROJECT CONTACT i TELEPHONE I <br /> Bob Feiseltin?. - <br /> F FACILITY NAME Mildred De V3_ncenzi(owner) PHONE M 20 31-3486 <br /> A <br /> C ADDRESS 21 167 N. Trethewa Rd. n <br /> I rpoo- CA <br /> L [ROSS STREET Acamho Rd. <br /> I <br /> T OWNER/OPERAIORMildred De Vincenzi PHONE R (209) 931--3486 <br /> Y 12267 E. Eight Mile Rd. Stockton, Calif. <br /> C CONTRACTOR NAME Jim Thorpe Oil Inc. / D.B.A. Rich-Mart Const. PHONE 111 209)368-6175 <br /> ° 51 N. Beckman Rd <br /> N CONTRACTOR ADDRESS Po. Bx. 357 hada Cal, 95210-03571 CA LIC 04 56 cLAss A B 11az <br /> 1 <br /> R INSURER Firenlatib bund / Admiral WORK cGMP r 1095135--90 <br /> AFire perm>�t will be <br /> flat DISTRICT San Joaquin Co / Mokelume [EhY'a�reUrep_ z u <br /> 0 LABORATORY NAME Weston Analytics 212 Frank West Cir. Stkn. ,Ca. PHONE Ir (209) 983-1340 <br /> R <br /> SAMPLING FIRM Same as above PHONE 0 Same as above <br /> - <br /> 111111111111111191111111111 <br /> - <br /> TANK ID TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39 ___55n gal — Res" IIr.F�nn_r - <br /> A 139- <br /> of <br /> 39 <br /> K 39- <br /> 39 <br /> 39 <br /> IIf1fIlI1111111111111111111111 IIII fill III Hill 1111111111111111 1111111111111111111111111111111111Hill 111111111111111111111 <br /> P <br /> L ___ _ APPROVED APPROVED WITH CONDITION(S) — DISAPPROVED <br /> A (SEE ATIAC194EXI WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME_ > � DATE <br /> -I 111111111111111111111111111111111111111111111111111111111111111111111111111111111Hill11111fI111111111 II1111111111111111I1 <br /> APPLICANT ITUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALIO SERVICES OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES IHE FOLLOWING. 111 CERTIFY THAI IN <br /> THE PERFORMANCE Of TOE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TD WORKER'S COMPENSATION LAWS OF CALIFORNIA " CONIRACIOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TOE FOLLOWING. <br /> "1 CERTIFY THAI 10 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, T SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> ENSAIION LAWS OF CALIFORNIA." <br /> i <br /> APPLICANT'S SIGNATURES TITLE Contractor DATE 5/28/91 <br /> EH 23 046 (Rev 2/8/91) It Page 1 <br />