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y <br /> 1 <br /> ENVlRoNMERIAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> r <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE Of UNDERGROUND HAZARDOUS SUaSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 OATS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHAVER AREAS". INDICATE PERMIT TYPE BELOIIS <br /> IE <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> I — <br /> EPA SIVE I CAD 0432 4380 PROJECT CONTACT R TELEPHONE a Todd Teresi (209)3.68-2472 <br /> FACILITY NAME 1 RHONE (20 368-24 2 <br /> Teresi Trucking <br /> ADDRESS 900 1/2 E. Victor Rd. Lodi CA 95240 �S <br /> CROSS STREET Beckman Rd. <br /> OWNER/OPERAIOR PHONE A <br /> Same as above L ° (209)368-2472 <br /> CONIRACTOR NAME jJill ��IUt'�)C Oil 1110. ;7 <br /> PHONE ! (20 h62-4531 <br /> 13 <br /> COMIRACfOR ADOREs$351 N Beckmall Bd. P.0.13X. 357 CA LIC r /ji g() 1 CLASS <br /> a e nip <br /> 4--n-s---. Ful c� <br /> I{, 410RK.COF4P.N �- <br /> INSURER Pir•esmati5 Fund/ Pacific 1 nsur. Co. , LTD <br /> FIRE DISTRICT The City Of Lodi l PERMIT On a r0 plan <br /> 1 LABORATORY NAME GeoAnalytical Laboratories P,NONE M (209)572-0900 <br /> W , m as above PNONE N (209)572-0900 <br /> SAf PI 1 HG FIRM RN Sa a 3.6 <br /> i I Il Tit 11111111111�lill l 111111 <br /> TANK lD T NK S CHEM L! Si !;D CURRENTLY/PREVIOUSLY DTE UST INSTALLED <br /> 3q_ �7 —0 1 ,004 ga� on waste Til 1972 <br /> 39- <br /> , <br /> 39- <br /> n. <br /> 79- <br /> T9- <br /> 79 .z <br /> l�iiilrllnn�lln��nrrnrrn lrrrnnl�nnnrrrnlnnnnlr I»1�Irnnj��rrntrn "ininrrininir rmitrmrrrnniin <br /> XAPPROVED APPROVED WIT" COHDI11011(S) _I DISAPPROVED <br /> SEE ATTACHMENT WITH CONDITIONS) <br /> ' Pt AN REYlE111111111111111111111TT1iiiilliI�ERS NAME �,�� 'I DALE <br /> - In i111ii1fi111 iiniiiliniiiiiiiiiiiiinuii111111iii 111 Til iTFiiTiiiiill <br /> A1`PLICAHT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAM JOAOUIN C01NI1T ORDINANCES,J�STATE lAWS, AND RULE! AND REGULATiDNS OF <br /> SAN JOAOUIR CCUNIY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWIHGs "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF iRE WORK FOR WHICH THiS PERMIT IS ISSUED, 1 SHALL Hof EMPLOY A11Y PERSON IN SUCH A MANNE0. AS i0 BECOME <br /> SUBJECi TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THEK ►OR WHICH TRIS PERMIT IS ISSUED, 11514AlL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> C011PEHSAii09 LAWS OF CALTFOR�" _� <br /> °� 4/18/94 <br /> APPLICANT'S SIGNATURES �►� L--� TITLE Cottt DATE <br /> � I! <br /> C <br /> 1 23 046 (RevIled 1/10/92) Page ] <br /> d <br /> ' � it <br />