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(• le Cne� <br /> ~ ' ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT lam' !n1 <br /> • <br /> APPLICATION FOR pERHANENT/iEORA ��MP RY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS It 'I <br /> THiS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. IMOIJ PERMIT TYPE BELOW: <br /> Y i <br /> ," <br /> _ RE140VAL TEMPORARY CLOSURE ABANDONMENT IN PLACE ' N 9 19 91 <br /> EPA SITE R PROJECT CONTACT & TELEPHONE 0 =L HEA H <br /> CAC 000601440 Bobt <br /> F FACILITY NAME Mildred De Vincenzi(owner) PHONE 0 (20 31-3486 <br /> A <br /> C ADDRESS 21167 N. Tretheway Rd. '9pa,-Ca <br /> T <br /> L CROSS STREET AcamPO ]fid <br /> I <br /> T OWNER/OPERATOR Mildred De Vincenzi PHONE N (209) 931-3486 <br /> Y 12267 E. Eight Mile Rd Stockton, Calif. <br /> C CONTRACTOR NAME Jim Thor2e Oil Inc. / D.B.A. Rich-Mart Const, PHONE N (209)368-6175 <br /> 351 N. Beckman Rd <br /> N CONTRACTOR ADDRESS Po. BX. 357 Lodi Cal. 95241-03571CA LIC 0 495699 <br /> CLASS A B Haz. <br /> T <br /> R INSURER Firemalis Fund / Admiral WORK COMP.# 1095135-90 <br /> A <br /> C FIRE DISTRICT Mokelullne PERMIT K Fire permit will be <br /> San Joaquin Co. / <br /> T <br /> 0 BORATORY NAME Weston Analytics 212 Frank west Cir. Stkn ,Ca. PHONE 0 (209) 983-1340 <br /> R <br /> SAMPLING FIRM Same as above PHONE N Same as above <br /> illllillllll[ifllllillliiillll <br /> TANK ID a/ TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE USi INSTALLED <br /> 39- <br /> T 39 CJ50 galRegular r-apQ]'-we <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39 <br /> 39 <br /> 1111111111i11[I1i11111[i[1111[ 11111111111111111[![111i11i11111 1i11111III u1111111111111111111111[1111111111111111111111111 <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A �- (SE,E/ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME_ -Fl�� � N �T"� - -- <br /> DATE 1 II 1111i1I11111111II[f1111111111111111111111131111i11111[IIII[IIII <br /> 14 <br /> 1111111111111[1111111111111111111111111111 I [ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WiTH SAN JOAOUIN 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. Of 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 /> IVSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE• TITLE Contractor DATE 5/28/91 <br /> EM 23 046 (Rev 2/8/91) ft Page 1 <br />