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�sy R 00 FUR1460 <br />-NU <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. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />X— REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />© �i UOd eve- �LL �d �l ne_ �"Le�r���" Lo via �- f-2 S /.P� ^�Ch •tie �-(pu.�(�'�) <br />ER 23 066 (Revised 7/10/92) Pepe 3 <br />H D <br />EPA SITE i CAC 080756176 <br />1 PROJECT CONTACT L TELEPHONE i Lou Tvedt 481-4072 <br />PHONE i 209-948-1369 <br />FACILITY NAME Airport <br />AF <br />,�.nge <br />C <br />ADDRESS 2305 S. Airport Way , Stockton, CA <br />I <br />L <br />CROSS STREET 10th Street <br />I <br />T <br />OWNER/OPERATOR <br />PHONE i <br />Y <br />Willie Billingsly <br />C <br />CONTRACTOR NAME Pa dirt Excavating Co. Inc. <br />PHONE i 209-599-2347 <br />0 <br />N <br />CONTRACTOR ADDRESS 269 Oregon ST. Ripon, CA <br />CA LIG i 680679 <br />CLASS <br />T <br />R <br />INSURERS. N. Potter Ins. Agency <br />WORK.COXP.i FR WC2 0011206D <br />A <br />C <br />FIRE DISTRICT Stockton Fire District <br />PERMIT i <br />T <br />0 <br />LABORATORY NAME Sherwood Laboratory <br />PHONE i 209-667-5259 <br />R <br />Del-TEch PHONE i <br />SAMPLING FIRM 209-847-8757 <br />TANNK 10 i TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />T <br />39- <br />T <br />39• 0— <br />—� £a on <br />P_a o i n <br />A <br />39- <br />9 <br />39- <br />K <br />39- <br />3q_ST I iA <br />2T,UUU galion <br />iese <br />uii m r mTrrmmmnrrrr� <br />P <br />L APPROVEDA APPROVED WITH CONDITION(S) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) (� <br />N PLAN REVIEWERS NAME DATE <br />mrrrmrmmmrmrrnnimm����� <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: 'I1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON 1N 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA.",, <br />1� <br />APPLICANT'S SIGNATURE: s:,' b TITLE L.+ P C7 DATE <br />© �i UOd eve- �LL �d �l ne_ �"Le�r���" Lo via �- f-2 S /.P� ^�Ch •tie �-(pu.�(�'�) <br />ER 23 066 (Revised 7/10/92) Pepe 3 <br />H D <br />