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ENVIRONMENTAL HEALTH DIVISION . <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION TANK <br /> THIS PERMITOE%EXPIRES 90DAYSFFRROARMYTHE�APPROVALE ON ADATTEE. DOT IN PLACE NOT WRITE ION ANYUNDERGROUND <br /> SHADD DDARREEAS.HAZARDOUS <br /> ETANRMITTTTYPEEBELOWI <br /> ( �(.ry� 7�(�(� A_ REMOVAL TEMPORARY CLOSURE CLOSURE IN DP,UCE I'C�C p <br /> EPA SITE 0 �,}{M00739056 PROJECT CONTACT i TELEPHONE 0 ATTORNEY BoSCOE(1O9)`65562O <br /> F FACILITY NAME ESTATE OF HICKINBOTHAM, ET,AL, PHONE fAGENT(209)465 5628 <br /> C ADDRESS 816 E, HAZELTON AVENUE, STOCKTON, CA 95203 <br /> CROSS STREET <br /> ! BETWEEN AURORA & GRANT <br /> 1 <br /> I PpHONE f <br /> T OWNER/OPERATOR <br /> Y ESTATE OF WILLIAMS , ET AL- rbuJi �Luy/ 5 �u�u <br /> C CONTRACTOR NAME AMES i PRONE <br /> 0 r. <br /> N CONTRACTOR ADDRESS �' CA LIC CUSS,, <br /> R INSURER It <br /> RI <br /> APERMIT f <br /> C FIRE DISTRICT CITY OF STOCKTON <br /> 0 LABORATORY NAME SPARGER TECHNOLOGY, INC, PHS o616) 362 8947 <br /> R SAMPLING FIRM UPGRADIENT PHONE If (916) 452 2891 <br /> TANK ID 9 TANK SIZE CXENICALS S10RED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39 ,,; 1,UO0 GASOLI NE LEADED UNKNOWN <br /> 1 39- <br /> A 39- <br /> N 39- <br /> K 39- I- <br /> 39- <br /> 39• I�liliiii))� NN <br /> P <br /> iii <br /> L APPROVEDADPROVED WIiN CONDITION(s) DISAPPROVED <br /> A AD- (S E ATTACHMENT WITH COITIONS) y J <br /> N PLAN REVIEWERS NAME TTDATE <br /> �E�TT� — <br /> IIIIIIIIIIIIIIIIIIII 1111111 ����� <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 AGEF1'S SIGNATURE CERTIFIES THE FOLLC(N7KG: N! CERTIFY THAT IW <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CJMLIFORRI)N.- <br /> APPLICANT'S SIGNATURE: TITLE `-�`^�f DATE <br /> EH 23 046 (Revised 7/10/92) Page-' e <br />