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M ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> RMIT TYPE BELOW: <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE . DO NOT WRITE IN ANY SHADED AREAS . INDICATE PE <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # PROJECT CONTACT B TELEPHONE # Floyd Barnes ( 209 ) 463-8636 <br /> F FACILITY NAME G U 209 ) 463-8636 <br /> Barnes Trucking <br /> A <br /> f c ADDRESS 1817 S . Fresno Ave . Stockton , Ca . 95206 <br /> I <br /> r <br /> L CROSS STREET Charter Way <br /> PHONE # <br /> T OWNER /OPERATOR <br /> Y Same as above Same as above <br /> l PHONE # <br /> C CONTRACTOR NAMEJim Thorpe Oil DBA Rich-Mart Construction Co . 20 4 2-4 8 <br /> o <br /> N CONTRACTOR ADDRESS 351 N . Beckman Rd . CA LIG # 4 6 class A/B /Haz . <br /> P . O . Bx . 357 Lodi Ca . <br /> I WORK . COMP . # <br /> R INSURER Firesman Fund Admiral <br /> A PRMIT # Fire permit will be <br /> C FIRE DISTRICT City of Stockton 06ained upon closure approv 1 <br /> T PHONE # <br /> 0 LABORATORY NAME GeoAnalytical ( 209 ) 572-0900 <br /> R PHONE # <br /> SAMPLING FIRM Same as above <br /> me 9613� <br /> IIIVIIIIIIIIIIIIIII " IIIIIIII TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK ID # <br /> 39 - lE'.Sel %uel <br /> T 39 - 7C-/�6 -^ .�� r ga <br /> A 39 - in 000 <br /> N 39- <br /> K 39 - <br /> v 39 - <br /> E 39 <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIII <br /> PAPPROVED APPROVED WITH CONDITION ( S ) DISAPPROVED <br />! A ( SEE ATTAC MENT WITH CONDITIONS ) DATE _� <br /> H PLAN REVIEWERS NAME <br /> IIIIIIIIIIIIIIII' IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII <br /> QUIN COUNTY ORDINANCES , STATE LAWS , AND RULES AND REGULATIONS OF <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOA <br /> SAN JOAOUIN 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 , 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> NTRACTOR ' S HIRING OR SUBCONTRACTING SIGNATURE <br /> SUBJECT TO WORKER ' S COMPENSATION LAWS OF CALIFORNIA . " COCERTIFIES THE FOLLOWING : <br /> " 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER ' . <br /> COMPENSATION LAWS OF CALIFORNIA . " _ <br /> TITLE Contractor DATE <br /> 4 / 24 /92 <br /> APPLICANT ' S SIGNATURE : <br /> l <br /> i <br /> Page 3 <br /> EH 23 046 ( Rev 2/0/91 ) ft <br />