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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 /> f EPA SITE # CAC000876608 PROJECT CONTACT & TELEPHONE 0 PETER F. PERSIC <br /> F FACILITY NAME PHONE # (113) 877 5-247 <br /> A <br /> C ADDRESS 221_225 MINER AVENUE <br /> I <br /> L CROSS STREET SAN JOAQUIN <br /> 1 <br /> T OWNER/OPERATORPHONE # <br /> Y M.J. BEVANDA PROPERTIES (213) 877 524/ <br /> C CONTRACTOR NAME PHONE # <br /> D EALcoN FNFR(;y (911-19) 463 /108 <br /> N CONTRACTOR ADDRESS .V 1]ll P fl D. STOCKMN, - CA LIC # CLASS <br /> T I <br /> R INSURER ON FILE WORK.COMP.# ON F-J IF <br /> A <br /> T FIRE DISTRICT CITY OF STOCKTON PERMIT # <br /> C LABORATORY NAME SPARGER I ECHNOLOGY INC PHONE # (J16) 62 891 <br /> t <br /> R © <br /> SAMPLING FIRM n1 t1PNONE <br /> 111111111111111 � jfj1I1� RNATIONAL (510) 7911986 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- SCT�TF—I [MIn r_n i EST r rn n9r T NE EST l Yl Q'S <br /> i A 39 '� �El -t— <br /> N 39- ' <br /> K 39- <br /> 39- <br /> 39 <br /> 1111 r �� <br /> P <br /> L y� APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> Aa SE ATTACHMENT WITH CONDITIONS) <br /> I N PLAN REVIEWERS NAME <br /> 1 I I 111111111 I!1111!1 nT1�I'�Tf1T[TiTfTiTrIT�TTf[TI i DATE <br /> I �� <br /> f�r�P�LG41ii 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 THAI 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." fjl� <br /> APPLICANT'S SIGNATURE: TITLE V.P. DATE I W 3 <br /> l .X�C� LCJ� f�li�`t✓L IG�j'1 vv! Q ��/j � 'I� 1!�/ �--� <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />