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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 # - - - PROJECT CONTACT 8 TELEPHONE OF ,JACK FRANCISCO (703) 780 5372 <br /> F FACILITY NAME PHONE # (209) 943 7191 <br /> A <br /> C ADDRESS 4245 L. MAIN STREET, STOCKTON, CA 95215 <br /> 1 <br /> L CROSS STREET GERTRUDE <br /> I pL, <br /> T OWNER/OPERATOR 1/K. SACK FRANCISCO PHONE # (703) 780 53/2 <br /> Y <br /> C CONTRACTOR NAME FALCON ENERGY PHONE # (109) 463 7108 <br /> 0 P.O.N CONTRACTOR ADDRESS UBox 1257 GA LIG # 584524 CLASS <br /> T WORK.COMP.# <br /> R INSURER ON FILE ON FILE <br /> C i FIRE DISTRICT %NTEZUMA PERMIT # <br /> T <br /> 0 LABORATORY NAME SPARGER TECHNOLOGY, INC. PHONE # (916) 362 8947 <br /> REPICENE INTERNATNAL 7 D HS a <br /> SAMPLING FIRM IO -41 PHONE r (510) 7911986 <br /> TANK ID 0 TANK JaCHEM[ CU <br /> LS STORED RRENTLY/PRE IOUSLY DATE UST INSTALLED <br /> �MK IZ� p�45 , 1u <br /> 39- <br /> T 39- i <br /> N 39- <br /> K 39- — <br /> 39- <br /> 39- T HM ffnRuffffluffm <br /> PAPPROVED , APPROVED WITH CONDITION(S) — DISAPPROVED <br /> A (SE ATTACHMENT WITH CONDITIONS) /afJ� <br /> N PLAN REVIEWERS NAME Y�F�pY7�Y7�YY�YT �7- DATE �( / <br /> I'II"""t"'�'I"' ��1i{p11111f 11111illlli111111����� <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: "1 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 THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> 5 <br /> m:xicsn r-or-o SIGNATURE: TIT Lcy •1 DATE `!- t <br /> lr/YI Q �� o�p sG�GLX�- USI S�G{7 ONS <br /> EF 23 046 (Revised 7/10/92) Page 3 <br />