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F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PER,'VIIT <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />XX REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # CAL000029682 PROJECT CONTACT & TELEPHONE *BRYAN H. MUSCO (707)579-0250 <br />FACILITY NAME CHEVRON SERVICE STATION I PHONE # (209)368-8614 <br />ADDRESS 301 W. KETTLEMAN LANE, LODI I <br />CROSS STREET PLEASANT AVENUE <br />W44/OPERATOR <br />ROBERT MCC0M8 <br />PHONE # <br />(209)368-8614 <br />CONTRACTOR NAME MUSCO EXCAVATORS, INC. I PHONE # (707)579-0250 <br />CONTRACTOR ADDRESS 2155 NYLA PLACE, SANTA ROSA, 9540, CA LIC # 634117 CLASS A B C10 C21 HAZ <br />INSURER STATE FUND I WORK.COMP.# 1372895 1 <br />FIRE DISTRICT LODI FIRE DEPARTMENT I PERMIT # HAVE NOT SUBMITTED I <br />LABORATORY NAME SEQUOIA ANALYTICAL I COUNTY SACRAMENTO <br />SAMPLING FIRM <br />111111111111111111111111111111 <br />TANK ID # <br />39- 2170 ,I!'- f <br />T 39- 2171 a <br />A 39- <br />N 39- <br />K <br />39- <br />39- <br />I11111111111111111111111! II <br />GETTLER & RYAN <br />PHONE # (916)921-9600 <br />PHONE # ( 916 ) 631 -131 4 <br />TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />10,000 MID GRADE GAS 1983 <br />10.000 REG GAS 1gA7 <br />1-gn n n P R ERIiHi1q--✓ A S <br />nn <br />i <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N PLAN REVIEWER'S NAME �F-+G- IG L-'' �jB DATE G� <br />11111111111111 I I I I11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <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." �, I <br />& / /Carte-� <br />APPLICANT'S SIGNATURE: O TITLE PRESIDENT DATE 7/13/98 <br />i -- i _r— -1 w' T q-_- i 5 S u LS%, Tjtk—' <br />CONDITION(S): jJ 'V — - - <br />t��t %c'� ?� J'S� G, �r/%T� ,r/�€• Sow�l,�A, /� r -L <br />GIi i Aef5 ,�..a�,G) -; 'rte—r/?%'S <br />Z�°t�o ; 6 Fi rC_ r, a%` . �V,a s <br />rr-17�' <br />ZO/ -`i ! 0 civ �/�i�F� i �7 mak'- ZA�e� <br />4 rrt) S4✓ ! <br />c <br />EH 23 046 (Revised /11/96) /h fl Page 3 <br />m, <br />