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SAN JO JUIN COUNTY PUBLIC HEALTH SOVICES <br />E VIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROL NO HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />0 REMOVAL <br />❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />FACILITY INFORMATION <br />EPASITE#CAcOO2257321 I PROJECT CONTACT PHONE# <br />FACILITY NAME CAPITOL AUTO SALES PHONE <br />ADDRESS 650 E- MINER AVENUE STOCKTON CALIFORNIA q5202 <br />CROSS STREET STANISLAUS STREET <br />OWNEROPERATOR JAGENDER SINGH _ PHONE# 20 466 9082 <br />TANK INFORMATION <br />APPLICANT <br />CON-; RACTOR INFORMATION <br />CONTRACTOR NAME JIM H 0 B <br />IT7FI I PHO IIE <br />CONTRACTOR ADDRESS B 0 X <br />0 C. CA LIC # CLASSA-HaZ <br />INSURER N / A <br />WORKER COMP# <br />FIREDISTRICT CITY OF STOCKTON PERMIT# .. <br />LABORATORY NAME SEQUOIA <br />ANALYTICAL COUNTYSACRAM EN IPHO_IE I <br />SAMPLINGFIRM DR. VICTOR <br />CHERVEN RG PHONE k (20q) 772 3620 <br />TANK INFORMATION <br />APPLICANT <br />TANK ID # <br />TANK SIZE —. TANK CONTENTS (PRESENT & PAST) <br />DATE INSTALLED <br />39- <br />L <br />/DATE <br />9- <br />39- <br />i <br />DAT <br />PLAN REVIEWER'S NAM , <br />39- <br />39-39- <br />COMM C <br />OVAL P5�ijft TO _EN <br />ANY DEVIATIONS FROM THIS APPUCATION MUfiT k SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMEN:IN ORKO <br />139- <br />CONDITIONS: <br />39- <br />39- <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAW.', FEDERAL LAWS, AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING. -1 <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR NHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY P.NY PERSON IN SUCH A MANNER AS <br />TO BECOME SUBJECT TO WORKER'S COMPENSATION LMS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLO`MNG'. 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWSOFCALIFORNIA\jA CJ) <br />APPLICANTS SIGNATURE fl \�-�C/ J"�''�� TITLE 4 � /— _______DATE 7' <br />CONDITIONS BE• ON ATTACHMENT) <br />I <br />/DATE <br />i <br />DAT <br />PLAN REVIEWER'S NAM , <br />dorz <br />COMM C <br />OVAL P5�ijft TO _EN <br />ANY DEVIATIONS FROM THIS APPUCATION MUfiT k SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMEN:IN ORKO <br />CONDITIONS: <br />U _ <br />AM <br />-4'6 Mfjp:-joFp <br />. �� <br />'WARR <br />IN <br />"ll p"Em <br />