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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. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # CAC 0008 0416 PROJECT CONTACT R TELEPHONE # Alda Fre air0 (209)946-0246 <br /> F FACILITY NAMEThe Part of Stockton PHONE # (209)946-0246 <br /> A <br /> C ADDRESS 2201 W. Washington St Road B Stockton CA <br /> 1 <br /> L CROSS STREET Navy Dr. <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y The Port of Stockton (209)946-0246 <br /> C CONTRACTOR NAME Jim Thorpe Oil. Inc./Rich-Mart Construction PHONE # 20 368-61 <br /> 0 <br /> H CONTRACTOR ADDRESS 351 N. Beckman Rd LodiCa. 95240 �' LIC # 4 56 CLASSA B Haz. <br /> T WORK.CoMP.# <br /> R INSURER Firemans Fund/ New England <br /> 0 - <br /> A <br /> C FIRE DISTRICT PERMIT # To be arranged <br /> T - <br /> 0 LABORATORY NAME GeoAnai tical Laboratories PHONE # 20 572-0900-- <br /> R <br /> SAMPLING FIRM Same as above PHONE # 2072-0900 <br /> III 1111111111IIIIIIIIIIIIIIill <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- 600) gal 1 ori unknown <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> IIII / r <br /> L PROVED i ,ARPROVED Yi,T0�CONDITION(S) _ DISAPPROVED _ <br /> EE A T 'WiTH CONDITIONS) <br /> N PLAN REVIEWERS NAME r, ©ATE <br /> IIIIIIIIIIIIIIIIIIII IIIII <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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I 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 PERFORMANC E WORK FOR W THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER"S <br /> COMPENSATION LAWS OF CALIFORNI . <br /> APPLICANT'S SIGNATURE: TITLE COntract0r DATE _ 4/r7'l//Qq <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />