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.. .. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR 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. INDI <br /> CATE PERMIT TYPE BELOW: <br /> -X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # CAL 000029685 PROJECT CONTACT 8 TELEPHONE #Maggie MCLdu hlin/ (707) 765-1660 <br /> F FACILITY NAME Chevron U.S.A. ! PHONE # 209 836-2119 <br /> A <br /> ( ADDRESS 3775 Tracy Blvd. <br /> L CROSS STREET Larch <br /> I <br /> T OWNER/OPERATOR PHONE 9 <br /> Y Chevron <br /> C CONTRACTOR NAME I I PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS )L�OtCA LIC # CLASS <br /> T <br /> R INSURER WORK.COMP.# <br /> A <br /> C FIRE DISTRICT TaaC Fire District PERMIT <br /> T <br /> 0 LASCRATORY NAME PHONE # <br /> R <br /> SAMPLING FIRM PHONE <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE U57 INSTALLED <br /> 39- 1 OS 0 gal used oil 1970 <br /> T 39- Y0,000gal mo or v hi rle fuel 1970 <br /> A 39- <br /> a,l — b,UUU gai <br /> N 39- gal 197F <br /> K 39- <br /> 39- rr <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> PLAN REVIEWERS <br /> NAMDATE <br /> APPLICANT MUST PERFOR ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAWIN COUNTY P BLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF 1HE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKERYS 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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> DD J 95 <br /> APPLICANT'S SIGNATURE: I r•H• (FE TITLE ��77%/�� DATE <br /> EH 23 046 (Revised 4/26/94) Page 3 <br />