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CLOSURL „r ALANDONMENT Telephone 1) 40-3 :V ' <br /> - T, I <br /> �{� t�filSlfx:SSlEldl��rS:l:"S'!1!!!!!:!!"�::7f!!:�!!"kll7Nf:�lS#fiSFntSfS:fllfl�?fS+S:S1fSfffSlSi, :gSi!!�f! <br /> 3 <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> -_ ---- m Y <br /> EPA SITE 1 PROJECT CONTACT & TFELEPHONE II <br /> CAC-000-147893 Georcre Je son 714 385-5795 <br /> F FACILITY NAME Laura Scudders PHONE 1 (209) 835-6300 <br /> A <br /> r ADDRESS 100 Valpico Road, Tracy, California <br /> I — <br /> L CROSS STREET Tracy Boulevard <br /> I <br /> T OWNERIOPERATOR same as above PHONE, I same as above <br /> Y <br /> C CONTRACTOR NAME Precision Industries, Inc. PHONE! 1 (209) 462-9911 <br /> N CONTRACTOR ADDRESS 1,041 S. Pershinc Ave., Stockton CA LIC 1 467293 CLASSA & S <br /> r <br /> R INSURER Ohio CasualtyWORK.COMP.I WCW(89)400-96-87: <br /> A -- <br /> C FIRE DISTRICT Trac, Fire PERMIT VINSPTR , <br /> T __--_ <br /> 0 LABORATORY NAMEPoy F Weston PHONE'1 (209) 957-3405 <br /> R <br /> .L <br /> SAMPLING FIRM* Roy F. Weston SAMPLING METHOD brass tube <br /> TANK ID 1 TANK SIIE ICHEMICALSf STORED CURRENTLY CHEMICALS STORED PREVIOUSLY <br /> T <br /> G� la oo LD diesel fuel diesel fuel <br /> 2,000 I c} unleaded qasoline in <br /> K 31 <br /> 3q----------------------------- <br /> ��-------------------------- <br /> ---------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P APPROVED APPROVED WITH CONDITIONS �� DISAPPROVED <br /> L (SEE ATTACHMERL WITH CDN TIONS) <br /> A PLAN REVIEWERS NAME __��_ DATE <br /> gum <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAOUIN LOCAL HEALTH DISTRICT, OWNER. 09 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORT; FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER, AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> :R <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED _ DATE <br /> OFFICE-USI-ONLY --------------------------------------------------- ----- ----------- »------ <br /> -------- <br /> _ .__ ------------ <br /> Ms Sititiittit;iitiitii;;;itiitifi;ii;iiit;iii;iiiii;iti;iittiii;ii;iiiiitiii;iii;;f;iifiiiiifi; <br /> %ICEPS I ' COMP I 'LOC CODE 'DIST CODE' AMOUNT DUE AMOUNT PCVD CKIICASH RCVD BY DATE P.CVO PERMIT I <br />