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ENVIRONMENTAL REALTII DIVISION <br /> APPLICATION FON 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 /> EPA SITE A' CAC'000739056 PROJECT CONTACT 6 TELEPHONE • ATTORNEY BOSCOEU09)4655628 <br /> F FACILITY NAME ESTATE OF4;fE4(dNBOTUAM, ET.AL. PHONE #AGENT(L09A65 5628 <br /> C ADDRESS 816 E. HAZELTON AVENUE, STOCKTON, CA IJ5203 <br /> 1 <br /> L CROSS STREET BETWEEN AURORA & GRANT <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y ESTATE OF HICKINBOTHAM, ET-AL. AGENT (209) 465 5628 <br /> C CONTRACTOR NAMEPHONE k - { <br /> 0 <br /> N CONTRACTOR ADDRESSpo . CA LIC 07F,-. CLASS,,All <br /> N <br /> R INSURER WORK.COMP.r rI!� <br /> A <br /> C FIRE DISTRICT CITY OF STOCKTON PERMIT # <br /> T <br /> 0 LABORATORY NAME BPARGER TECHNOLOGY, INC. PHONE # 616) 562 8947 <br /> R SAMPLING FIRM UPGRADIENT PHONE # (916) 452 2891 <br /> TANK <br /> _ TANK )D / TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- � -- . c 1,000 GASOLINE. LEADED UNKNOWN <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> iiii rrm r �n�rrr <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVE;RU�LES <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS WANE t►TYi�iTiT7itTt�T��TTTTTt���i7i�i�T��YY��7-7F7��7�T'7�T�DATE <br /> I"II"I"I�I�I�"" IFIIIIIFLLLFF11111111111111111����� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, ANDD REGULATIONS OFSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOL : "1 CERTIFY THAT IN <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 CAL1FOP,9101.- <br /> APPLICANT'S SIGNATURE: -� _ TITLE DATE <br /> EH 23 046 (Revised 7/10/92) Page_, <br />