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1 <br />' ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE R LAC 000827296 PROJECT CONTACT & TELEPHONE I Steve Yo affil (20q)948-0520 <br /> F FACILITY NAME Riverside Cement Co PHONE I (2Q9)q48-0520 <br /> 1 ADDRESS <br /> 2825 W. Washington St Stockton Ca, <br /> L CROSS STREET Navy Dr. <br /> C+WHER/OPERATOR PRONE 0 <br /> Riverside Cement Co. Oro Grande, Ca 92368 (619)2+5-5321 <br /> C CONTRACTOR NAME Jim Thorpe 011 Inc./Rich-Mart Construction PHONE 0 (209)368, 61 <br /> 1 CONTRACTOR ADDRESS 351 N. Beckman Rd Lodi Ca. 95240 1 CA LIC 0 4956 CLASS A B Haz. <br /> R INSURER F)xema113 Futid/ New England WORK.CoMP A 1095U5-90 <br /> IRE DISTRICT City of SLockton PERMIT 0 To be arranged <br /> 0 LABORATORY NAME GeoAtlal tical Laboratories PHONE * 20 512-0900 <br /> R <br /> SAMPLING FIRM Satre as above PHONE * 20 _ <br /> IIIIIIIiillllllllllllllllllil <br /> TANK ID TANK SIZE CHEMICAL STORED CURRENTLY/PREVIOUSLY DATE <br /> �UST INSTALLED34_ — r"l rr-�onl ono. 197f) 7 - <br /> 1 '000 GAJ <br /> 39- <br /> 39- <br /> 39- <br /> K 39- <br /> 39- <br />�- � <br /> 39- <br /> L <br /> iEL PPR D PP D Vt1 -e ITION(S) DISAPPROVED <br /> NEXT WITH C OHS) <br /> PLAN REVIEWERS N E DATE <br /> fill 11111111111111 ir1 1 i <br /> APPLICANT RUST PERFOR L! WORK IN ACCORDANCE WITH SAN JDADUlN COUNTY ORDINANCES, TATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUlN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CE TI€IES THE FOLLOWING: "I CERTIFY THAT IN <br /> 111E 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 10 WORKER'$ COMPENSATION LAWS OF CALIFORNIA " CONTRACTOR'S HIRING OR SUBC TRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH IS PERMIT IS ISSUED, 1 HALL EMPLOY PERSONS SUBJECT TO WORKERIS <br /> ICIIIIE"IATIOR LAWS OF CAtIFORNIA." <br /> APPLICANTS SIGNATURE. TITLE Contractor DATE 10/19/92 <br /> P�- <br /> 23 046 (Revfsed 7/10/92) Page 3 <br />