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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PF.RMANENTfIIMPORARY 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 /> EPA CITE#: CAC001026984 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 /> O ADDRESS: 351 N. BECKMAN RD. PO BOX 357 CA LIC#: 495699 CLASS: A.B.HAZ <br /> N <br /> T INSURER: LANDMARK & GENSTAR WORK COMP# STATE COMP.INS. FUND- 1095135 <br /> R <br /> A FIRE DISTRICT: The City of Stockton PERMIT# on approval of plan <br /> C <br /> T LABORATORY: GEOANALYTICAL LABORATORIES PHONE# (209) 572-0900 <br /> O <br /> R SAMPLING FIRM: GEOANALYTICAL LABORATORIES PHONE# (209) 572-09M <br /> TANK HN{ TANK SIZE c"muCAIS STORED cURREmmy/PREvIOUSLY DATE UST INSTALLED <br /> T <br /> A 39-1105-02 1000 GALLONS Unleaded Gasoline 1987 <br /> N <br /> K 39- 1105-03 1000 GALLONS Diesel Fuel 1987 <br /> 39 GALLONS <br /> 39 GALLONS <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> A <br /> ATTATC <br /> N W17H COND[TIONS) <br /> PLAN REVIEWERS NAME: � l/� DATE: /—/C-13 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES <br /> AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE <br /> CERTIFIES THE 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 IS 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) <br /> s <br />