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SAN Jr "QUIN COUNTY PUBLIC HEALTH SERVICES <br />� NVIRONMENTAL HEALTH DIVISI . r+ <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENTITEMPORARY 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 />M REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />TANK INFORMATION <br />FACILITY INFORMATION <br />INFORMATION <br />EPA SITE <br />PROJECTCONTACT Ron Palmquist <br />PHONE# 209-937-8320 <br />`FACILITY NAME <br />Gateway Project <br />PHONE# <br />ADDRESS i3iocic <br />Doundedy Lafayette, E1 Dorado, Center and <br />Sonora Street <br />CROSS STREET <br />39 - <br />I WORKERcomp# 430-98 <br />OWNER OPERATOR Redevelopment Agency of Stockton <br />PHONE# <br />TANK INFORMATION <br />CONTRACTOR <br />INFORMATION <br />39- Unknown <br />CONTRACTOR NAME Evans <br />Brothers Inc.PHONE# <br />925-443-0225 <br />CONTRACTOR ADDRESS 7589 <br />National Drive <br />CA LIC 111 443018 <br />CLASS A, Haz <br />INSURER State Fund <br />39 - <br />I WORKERcomp# 430-98 <br />FIRE DISTRICT <br />PERM", <br />LABORATORY NAME The Twining Laboratories, I <br />cDOUNTY Fresno PHONE#559-268-7021 <br />SAMPLINGFIRM The Twining <br />Laboratories, Inc. <br />I PHONE s - - <br />TANK INFORMATION <br />TANK ID # <br />I TANK SIZE TANK CONTENTS (PRESENT 6 PAST) DATE INSTALLED <br />39- Unknown <br />1,000 gal 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 PUBLIC 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 PER NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CAti 0 <br />APPLICANTS SIGNATURE I /I -TITLE , I"�w t� ' - -\ l � „ DATE 912 C <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 />