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SAN Jr NQUIN COUNTY PUBLIC HEALTH ° C`RVICES <br />- ��NVIRONMENTAL HEALTH DMS" <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENTMEMPORARY 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 cl ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />I 4- <br />i�4_i <br />TANK INFORMATION <br />-� FACILITY INFORMATION <br />INFORMATION <br />EPA S179 0 <br />PROJECT CONTACT Ron Palmquist <br />PHONE# 209-937-8320 <br />FACILITY NAME <br />Gateway Project <br />- PHONE N <br />ADDRESS Block <br />boundedy Lafayette, E1 Dorado, Center and <br />Sonora Street <br />CROSS STREET <br />; <br />- PERMIT # <br />OWNER OPERATOR Redevelo ment Agency of Stockton <br />PHONE # <br />TANK INFORMATION <br />CONTRACTOR <br />INFORMATION <br />CONTRACTOR NAME Evan <br />BrothersInc. <br />PHONEN 925-443-022 <br />CONTRACTOR ADDRESS 7589 <br />National Drive <br />CA LICA 443018 CLASSA Haz <br />INSURER State Fund <br />I wgRKERr0MP"30-98 <br />FIRE DISTRICT <br />; <br />- PERMIT # <br />LABORATORY NAME The Twining Laboratories, 1q}pU <br />sno PHONE A 559-268-7021 <br />SAMPLING FIRM The TwiningLaboratories, <br />Inc. <br />PHONE* - - <br />TANK INFORMATION <br />TANK ID s <br />I TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />39- Upkiiown <br />1 000 al Empty/Unknown 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 PUSUC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: -1 <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 -THF WORK FOR WHICH THIS PERMIT IS ISSUED. 1 SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br />APPLICANTS SIGNATURE TITLE /—J y EI <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 />�N CONDITIONS: <br />