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} ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUB <br /> TPERk SPBELOTl <br /> ENVIRONMENTAL PY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO HE <br /> OT WRITE IN ANY SHADED AREAS. INDICATE E BELO NEglTy <br /> PERMIT/SERVICES <br /> x REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE 0 CAC 000653040 PROJECT CONTACT & TELEPHONE 0 Jim Thorpe Oil Inc. (209)368-6175 <br /> F FACILITY NAME Boettcher Western Properties 111 , Ltd. <br /> PHONE I N/A <br /> A <br /> C ADDRESS 4555 N. Pershing Ave Stockton, Ca. <br /> I . <br /> L CROSS STREET Rose Marie Lane <br /> ( PHONE 0 <br /> 1 OWNER/OPERAtOR Boettcher Western.Properties 111 , Ltd. <br /> T 850 W. March Ln. Suite A Stockton, Ca. 95207 (209)473-8996 <br /> PHONE I <br /> C CONTRACTOR NAME Jim Thor e Oil Inc. / U.B.A. Rich-Mart Const. , 20 68- <br /> 6175 <br /> 1 . Beckman Rd CA LIC # CLASS <br /> N CONTRACTOR ADDRESS Vo. Bx. 357 Lodi Cal. 95241-035 4 56 A B Haz. <br /> T WORK.COMP-0 1095135-90 <br /> R INSURER Fir•ernaris Lurid / Admiral _• <br /> A PERMIT !Fire permit will be <br /> C FIRE DISTRICT City of Stockton � I'Dau_clPs <br /> T PHONE 0 <br /> 0 LABORATORY HARE Quality Assurance Laboratories (619)56a-1060_ <br /> R TreaTek Inc. PHONE j (209)472-2020 <br /> SAWCING FIRM - <br /> 1111111111111111111111111111!! TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK ID R p� 12,000 gal. Unleaded Gasoline <br /> t 39 , Pia ga . •,T ! warn-O leaded-Gaso�kne/ ? <br /> A 39 <br /> 12.000 gal.- <br /> Diesel Fuel <br /> N 39- <br /> 0 39- <br /> 39- <br />• 39- <br /> 1111111!1l1l1illlll!lI1111!lI11111111111111In 11 In 111111111 ill 111111111111111111111111111111!11111111 llill[111111i111l1111 <br /> P <br /> L APPROVED r APPROVED WITH CONDITION(S) DISAPPROVED <br /> A '� (SEE ATTACHMENT WITH CONDITIONS) <br /> DATE <br /> N PLAN REVIEWERS NAME <br /> 1111111111111111111111 Ill 11 Ill 11 Ill 111111111 Ill 11 Ill 11111111111111 Ill 1111111111111111!111111111 III II 11111 III li lil 111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JU4WIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS Of <br /> SAH JOACUIN 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 15 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 CERTIFT THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> TITLE <br /> DATE 11/13/91 <br /> APPLICANT'S SIGNATURE: � , <br /> a <br /> Page <br /> EH 23 046 (Rev 2/8/91) ft 1 <br />