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k r' <br /> q c <br /> 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 /> EPA SITE # CAD981971815 PROJECT CONTACT & TELEPHONE # Bradd Stately 510 426-2279 <br /> t FACILITY NAME RMC Lonestar PHONE # (209) 835-1454 <br /> A <br /> C ADDRESS 30350 South Tracy Blvd. , Tracy, CA <br /> i <br /> L CROSS STREET Lenne Road <br /> t, OWNER/OPERATOR RMC Lonestar PHONE # (209) 835-1454 <br /> C CONTRACTOR NAME PHONE # <br /> Pacific Excavators 510 370-8783 <br /> N CONTRACTOR ADDRESS P.O. BOX 965 CA LIC # A 605513 CLASS A <br /> t <br /> H INSURER Morgan Insurance Co. , San Jose WORK.COMP.#Morgan Insurance <br /> A <br /> C EIRE DISTRICT Tracy Rural Fire Dept. PERMIT # 209 835-1883 <br /> C LABORATORY NAME Chromolab PHONE # (510)484-1919 <br /> a <br /> ++SAMPLING FIRM Pacific Excavators PHONE # (510) 370-8783 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 39- IU,UUU gallon DieseI n a <br /> A 39- <br /> N 39- z IjUUOgallon Gasoline n a <br /> k 39- <br /> 39- gallon Waste i n a <br /> p <br /> i L s APPROVED APPROVED WITH CONDITION(S) a DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N ,PLAN REVIEWERS NAME DATE <br /> APPLICANT 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 COtJR ON LAWS OF CALIF IA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> ill CERTIFY THAT IN TH PERFORM OR WHICH THIS PERMIT IS ISSUED,.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORN A." <br /> APPLICANT'S SIGNATURE: TITLE Owner DATE 12-1-95 <br /> i <br /> SII 23 046 (Revised 4/26/94) Page 3 <br />