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SAN '7AQUIN COUNTY PUBLIC HEALT" SERVICES <br /> '*� ENVIRONMENTAL HEALTH DIV*mCN <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 /> EkREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPAsITE#CAC001446120 1 PROJECTCONTACT Bill Little HONE#90q 467100f; <br /> FACILITY NAME Rosenthal Trust Building - PHONE -0434 24 South American Street <br /> CROSS STREET Main Street at Stanilaus <br /> OWNEROPERATOR Rosent a Trust c/o Bank of Stockton PHONE#209 948-0434 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Advannprl rt-oT?.nvirnnmpnf-a1 inn PHONE# <br /> CONTRACTOR ADDRESS $ h CA LIC# CLASS <br /> INSURER Saint Paul WORKER COMP# 1117474-97 <br /> FIREDISTRICT Stockton CA PERMIT# n-f ' <br /> LABORATORYNAME Precision Environtech COUNTY SJ PHONE# 462-0892 <br /> SAMPLING FIRM recision EnvirOTe h PHONE # 4990992 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- 500-gallon waste oil unknown- <br /> 39- <br /> 39- <br /> 139- <br /> 1 39- <br /> 1139- <br /> APPLICANT <br /> nknown39- <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: "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 LAWS OF CALIFORNIA.- 4 /J <br /> APPLICANTS SIGNATURE TITLE RA&t 9b�M1{L'" DATE <br /> ❑ APPROVED PPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME CCJ DATE 't�J� <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE B ITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> r <br /> ud-J <br /> 3 <br /> EH 046(REVISED 8 13199) -- _ Page 3 <br />