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11 <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 SITEI6 / �, 050,— � PROJECT CONTACT & TELEPHONE # Bob Riley ( 209) 334-3411 <br />F FACILITY NAME _ PHONE # 9 334-3411 <br />c <br />A <br />C ADDRESS 975 S. Fairmont Avenue, Lodi , CA 95240 <br />I , <br />L CROSS STREET Vine Street <br />I <br />T <br />Y <br />OWNER/OPERATOR <br />Lodi Memorial Hospital <br />PHONE # <br />(209) 334-3411 <br />C <br />CONTRACTOR NAME tjjaV <br />PHONE # <br />0 <br />N <br />CONTRACTOR ADDRESS <br />/- <br />CA LIC # � �jZf� <br />CLASS A 1 <br />R <br />INSURER kWl <br />WORK.COMP.# <br />A <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />0 <br />TORY_ <br />PHONE # ' <br />R <br />Ij <br />SAMPLING FIRM PHONE # <br />1111111111111111111111 11 <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T 39• r l - <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />111! <br />P <br />L _ APPROVED APPROVED WITH CONDITIONS) _ DISAPPROVED <br />(SEE ATTNT WITH CONDITIONS) / 2� <br />N PLAN REVIEWERS NAME ��i G� / �LGI%�DATE <br />tlllllllllliltt111tf iTfT[ilTilllill <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <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, 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 CERTIFY 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 />APPLICANT'S SIGNATURE: TITLE DATE <br />EH 23 046 (Revised 7/10/92) Page 3 <br />