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SAN JC,,�UIN COUNTY PUBLIC HEALTH :�RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/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 /> Sample & Line Closure <br /> ❑ REMOVAL ❑ TEMPORARY CLOSURE M CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPASITE# needed PROJECT CONTACT Don Nathe PHONE# (209)943-7134 <br /> FACILITY NAME Airpnrt Walz laihp PHONE# <br /> ADDRESS - <br /> CROSS STREET Fremont St . <br /> OWNER OPERATOR Dori and Celia Nathe PHONE#(209)943-7134 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME lm orpe U11 , Inc. PHONE# 368-6175 ADDRESS CA LIC# CLASS <br /> INSURER WORKER COMP# <br /> FIREDISTRICT The Cityf Stockton PERMIT# <br /> LABORATORYNAME GeoAnal tical COUNTYStan PHONE# <br /> SAMPLING FIRM GeoAnalytical PHONE It <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- Remote Fill Waste Oil Unknown <br /> 39- <br /> 39- <br /> 39- <br /> 39- <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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING. 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMAI OF TH WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS 0 1 ORN <br /> APPLICANTS SIGNATURE LE Contractor DATE 3/13/00 <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME Z,4 DATE-. -106 <br /> ANY DEVIATIONS FROM 4S APPLICATION MUST WE JUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> ( J - <br /> 64A- <br /> EH 23 046(REVISED 10119/98) Page 3 <br />