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SAN JC JUIN COUNTY PUBLIC HEALTH ' 'VICES <br /> ENVIRONMENTAL HEALTH DIVISIOK <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 /> ® REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> L' Ao OZ9S OA--7 3 FACILITY INFORMATION <br /> EPA SITE# -4027 1PROJECT CONTACT George Takemori I PHONE# 916-386-6916 <br /> FACILITYNAME A. Teichert & Son Inc. - Stockton Shop PHONE# 209-946-8580 <br /> ADDRESS 103 North E Street <br /> CROSS STREET Weber <br /> OWNEROPERATOR A Tel pert & Son, Iri PHONE# 916-484-3011 <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME Triangle Inc. Of SacramentoPHONE# 916-421-19 <br /> CONTRACTOR ADDRESS 3525 52nd Avenue CA LIC# 183550 CLASS <br /> INSURER Legion Insurance Companv WORKERCOMP# WC3-0770013 <br /> FIREDISTRICT City Of Stockton PERMIT# <br /> LABORATORY NAME Columbia Anal tical COUNTY I PHONE# 408-437-2400 <br /> SAMPLINGFIRM pinnacle - I PHONE # 530-676-6884 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 394 /1 -U 20 , 000 Diesel 1972 <br /> 3 - ^0 20 , 000 Diesel 1972 <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 SMALL 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.1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br /> APPLICANTS SIGNATURE 1^-C)dz' TITLE Project Engineer DATE 12-1-98 <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 EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS' <br /> EH 23 046(REVISED 10/19/98) Page 3 <br />