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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # nae nnnnnnnan PROJECT CONTACT 8 TELEPHONE # A --_� /nnnN a -7n n -?nn <br />F FACILITY NAME Arco Eacility A 548 PHONE # 209) 4ZS-2723 <br />A <br />C ADDRESS 1612 West Hammer <br />I <br />L CROSS STREET Brentwood <br />I <br />T OWNER/OPERATOR PHONE # <br />Y ARCO INC. 415 571-2462 <br />C CONTRACTOR NAME Helmick & Lerner Inc. <br />PHONE # 4R5-7222 <br />0 <br />N CONTRACTOR ADDRESS 3750 Auburn Blvd. Sac. Ca. CA LIC # 589667 CLASS A- Haz <br />T <br />R INSURER State Compensation Insurance Company WORK.COMP.#1166709 92 <br />A <br />C FIRE DISTRICT San Joaquin County PERMIT # <br />T <br />0 LABORATORY NAME PHONE # <br />R <br />SAMPLING FIRM PHONE # <br />111111111111111111111111111111 <br />T N EO # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- _I <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />- 1111 <br />9-39- <br />"" <br />P <br />L EDPR N CONDITIONS) ® DISAPPROVED <br />A (SE ITN CONDITIONS) <br />N PLAN REVIEWERS NAME DATE ''( <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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: Y-4 4 � L — <br />TITLE �� ®a( "� DATE .-/( <br />EH 23 046 (Rev 2/8/91) ft <br />(Rev 4/8/91) <br />Page 3 <br />