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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTI TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> 01REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE-IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# CAL000029673 PROJECTCONTACT BRYAN MUSCO PHONE# 707-579-0250 <br /> FACILITYNAME CHEVRON SERVICE STATION I PHONE# ,- <br /> ADDRESS 139 S. CENTER STREET <br /> CROSSSTREET WASHINGTON STREET <br /> OWNEROPERAToR RONALD SANCHEZ PHONE# 209-467-1625 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME MUSCO EXCAVATORS INC. PHONE# 707-579-0250 <br /> CONTRACTOR ADDRESS 2526 GREENVALE COURT SANTA ROS A CA 95401 1 CA LIC#634117 CUSS(, B, C10, 121, <br /> INSURER STATE FUND WORKER COMP# 641833 ` HAZ, I IC <br /> FIRE DISTRICT STOCKTON FIRE PERMIT#W LL HAVE0 -SITE AT REMOVAL <br /> LABORATORY NAME LANCASTERCOUNTY PHONE# 8 <br /> SAMPLING FIRMCCUR PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT 8 PAST DATE INSTALLED <br /> 39- 3ae8s"olo3c, o5 10K REGULAR 1990 <br /> 39- i699a-p ID59 D6 10K MIDGRADE 1990 <br /> 39- 194 plD 10K PREMIUM 1990 <br /> j 39- 39998 g 1K USED OIL 1990 <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUSUC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO 13ECONIE SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING7 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATI WS O/,F, " `IC�ALIF�RNI'A.- Qy/I�I <br /> APPLICANTS SIGN ATU Jf 77 . LY/�`AA TITLE OFFICE MANAGER DATE 12/19/02 <br /> ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046(REVISED 08113199) Pepe 3 . <br />