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\-101 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT' <br /> APPLICATION FOR PERMANENTITE PORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES"DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL 7UNAPORARY CLOSURE CLOSURE IN PLACE <br /> EPA CITE#: CAC001026994 I PROJECT CONTACT&PHONE#(209)466-6766 Robert Miloslavich/owner <br /> F <br /> A FACILITY NAME: Polar Water, Inc. PHONE# (209)466-6766 <br /> C <br /> I ADDRESS: 1029 W. Fremont St. Stockton, CA 95203 <br /> L <br /> I CROSS STREET: San Jose St. <br /> T <br /> Y OWNER/OPERATOR: Robert Miloslavich PHONE# (209)466-6766 <br /> CONTRACTOR NAME: JIM THORPE OIL, INC. PHONE# 209) 4624581 <br /> C <br /> 0 ADDRESS: 351 N. BECKMAN RD. PO BOX 357 CA LIC#: 495699 CLASS: A.B.HAZ <br /> N <br /> T INSURER: LANDMARK & GENSTAR WORK MP#.STATE COMP. INS. FUND- 1095135 <br /> R <br /> A FIRE DISTRICT: The City of StocktonPERMIT # on approval of plan <br /> C <br /> T LABORATORY: GEOANALYTICAL LABtffRIES PHONE# (209) 572-0900 <br /> O <br /> R SAMPLING FIRM: GEOANALYTICAL L ORIES PHONE# (209) 572-0900 <br /> TANK ID# TANK E,' 'CHEMICMS STORED CURREVMY/PREVTOUSLY DATE UST INSTALLED <br /> T <br /> A 39- 1105-02 000 GALLONS Unleaded Gasoline 1987 <br /> N <br /> K 39- 1105-03 GALLONS Diesel Fuel 1987 <br /> 39 GALLONS <br /> 39 GALLONS <br /> P <br /> L APPRO APPROVED WITH CONDITIONS DISAPPROVED <br /> A <br /> N (SEE ATTATCHED WITH COMMONS) <br /> PLAN REVIEWE NAME: /`�y /�j�—�— DATE: —/ 7 <br /> APPLICANT MUS PERFORM ALL WORK IN ACCORDANCE WITH SAN IOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES <br /> AND REGULA NS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE <br /> CERTIFIES FOLLOWING: `I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I <br /> SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF <br /> CALIFORNIA.' CONTRACTOR'S HIRING OF SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: `I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.- <br /> APPLICANT'S SIGNATURE• TITLE: CONTRACTOR DATE:12/29/94 <br /> EH 23 046 (Revised 1/02/95) Par3 0Q <br /> t (y/(J7 / /J 0 p <br /> a "'p ;' 'dX„ y�... �— w � .5 c.:1V--4--`G` �' <br /> y- SY/� `X 7°. <br />