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IENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> ANCE <br /> TANK <br /> APPLICTION FR <br /> SN90TDAYSPFFRROMrTHEOAPPROVALADATE DOimot WRITE IN PLACE IN ANYESHADED DARE S. INDICATETPERMIT STORAGE <br /> TYPE BELOW, <br /> I <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE 0 CAC 00082 2 6 PROJECT CONTACT & TELEPHONE 0 Steve YO am - <br /> PHONE <br /> F FACILITY NAME Riverside Cement CO. <br /> ADDRESS 2825 W. Washington St Stockton Ca. <br /> CROSS STREET Navy Dr. <br /> [ PHONE 0 <br /> OWNER/OPERATOR (619)245-5321 <br /> Riverside Cement Co Oro Grande, Ca. 92368 <br /> C CONTRACTOR NAME ,�2tr1 Thor e 021 Inc./Rich-Mart Construction PHONE 20 368--61 <br /> CONTRACTOR ADDRESS 351 N <br /> Beck[Ilan Rd Lodi Ca. 95240 CA LIC 0 4 56 CLASS A B Haz. <br /> R INSURER Flrelnazis Fund/ New England WORK coMP.r2 10951-15-90 <br /> A PERMIT <br /> !RE DISTRICT '£O be arranged_ <br /> ABORATORT NAME Q1 ty of StnCkton <br /> PHONE 20 2-0 00 <br /> GeoAnal tical Laboratories <br /> R PHONE t! 2fl _ <br /> SAPPLINa FIRM Salne as above <br /> IIIIIIIIIIITANK II�I IIIIIIIIIII TANK 512E CHEMIGL STORED CURRENTLY/PREVIouSLY DATE UST INSTALLED <br /> 3q. 1 Q Ca -, - — ---11Y �1}� <br /> T 39- <br /> 1 A 39- <br /> N 39- <br /> 4 39 <br /> 39- <br /> 111wnMMMM <br /> 1 fT1i1TTTi1 FIRM <br /> L PPR D PP D ITIOH(S) DISAPPROVED <br /> A MENi WITH C ONS) <br /> N PLAN REVIEWERS H E DATE <br /> I!I!1##II#I11#1#II #R 1 1 1 i#1#I <br /> APPLICANT MUST PERFOR LL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, TATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUTA COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CE TIFIES THE FOLLOWING, "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE UORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> I "IBCERTIFYY THATEINSTHEE PERFORMANCELAWS <br /> Of THECAWORKOFORAWHICCONTRACTOR'S19 PMITHIRING <br /> ISSUED, IC HALLCEMPLOY SIGNATURE <br /> PERSONS SUBJECTCERTIFIES <br /> TOTHE <br /> WORKER'SWING• <br /> CCWPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE- <br /> TITLE Corntractor _ _ DATE 10/19/92 <br /> EH 23 1146 IRevlaed 7/10/92) Page 3 <br /> I <br />