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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION <br /> PERMIT EXPIRESN90TDAYSP FFROMYTH CSURE OR APPROVALABANDONMENT <br /> IN PLACE NOT WRITE OIN ANY UNDERGROUND <br /> AREAS.HAZARDOUS <br /> INDICATET PERMITSTORAGE <br /> BELOW: <br /> X_ REMOVAL TEMPORARY CLOSURE -_ CLOSURE IN PLACE <br /> EPA SITE x CAL 000029685 PROJECT CONTACT 8 TELEPHONE =Ma ie McLaughlin/ (707) 765-1660 <br /> F FACILITY NAME Chevron U.S.A. PHONE 0 (209) 836-2119 <br /> A <br /> C ADDRESS 3775 Tracy Blvd. <br /> I <br /> L CROSS STREET Larch <br /> I PHONE <br /> T I CWNER/OPERATOR <br /> Y Chevron <br /> CI CONTRACTOR NAME LIF. P67)eocEyM t/I(°M F/✓ 9' �o I PHONE <br /> NCONTRACTOR ADDRESS 1 O I CA llC (f 3.L 3 I CLASS �.3 G(o/-��� . <br /> T 2 <br /> R I INSURER I W'ORK.COMP.'. <br /> A I <br /> C I FIRE DISTRICT PERMIT <br /> I �/y ,F <br /> Tzac Fire District <br /> 0 LASCRATORY NAME S Vol �-L, -!(� LAE!) .OSW HONE : _2,( � 9000 <br /> R SAMPLING FIRM �♦Jc'ffSro/�� Si{- PRONE <br /> TANK 1D -•NK SIZE CHEMICALS STORED CU RRENTLT/PREV70'JSLY I DAT= L'ST INSTALLED <br /> 39- 1500 al used oil 1970 <br /> / 39- zal motor vehirlP fuel 107(1 <br /> A 39- a n n n O- <br /> N 39 gal1 i0 <br /> K .9 <br /> �9 !9- <br /> 11-1 IN 11111-111111111fil 1111111 HIM 11[111,1111 HIM 11111TI I F F111111111111111111 <br /> 11A <br /> APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> SSEB AT�EN'T 'WITH CONDITIONS) DATE /OiJ1 �PLAN REVIEWERS NAME <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOADUIN C'O'UNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. C.'NER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "F CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I 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 CX THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAW'S OF CALIFORNIA." �^ p <br /> C. D �Ta� '7 �o /Jr <br /> APPLICANT'S SIGNATURE: G. /' N• �E ! ATITLE �g Cft�°7Yfd✓ DATE <br /> urm_P2 s f� . <br /> t4�,n� 1p�P� �/XC c�tt `� &1-(_ //�C L 4 c,v.�A- 7Lc�// �c� o�/a�� &4"- <br /> -'If <br /> � �t c� <br /> EH 23 6 '<RevYsec /Yd/94AC!/'✓1'F-I/F'kC[!C-2�}' ?� Ut .�'C. <br />