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SAN .' QUIN COUNTY PUBLIC HEALTf ` IERVICES <br /> `-tNVIRONMENTAL HEALTH DIVI'-,eN <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE� <br /> SU,�RE PERMIT <br /> r` /e- ""r <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 /> Q� IN � 4 <br /> ® REMOVAL ❑ TEMPORARY CLO RE ❑ CLOSURE IN <br /> FACILITY INFORMATION <br /> EPA SITE#CAT080026362 PROJECT CONTACT Jonathan Yee PHONE# 916 972-6856 <br /> FACILITYNAME Pacific Bell PHONE# (209) 943-4014 <br /> ADDRESS 1413 Bourbon Street, Stockton, CA <br /> CROSSSTREET West Lane <br /> OWNER OPERATOR Pacific Bell PHONE# (209) 474-4019 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Fuller Excavating & Demolition Inc. IPHONE# (916) 858-8300 <br /> CONTRACTOR ADDRESS 3283Luyung Drive,Rancho Cordova, Ca. I CALK# 505228 CLASSC12 C21 C 1/D40 <br /> INSURER Legion Insurance Company WORKERCOMP# WC31189892 HAZ <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME COUNTY PHONE# <br /> SAMPLING FIRM 37 PHONE k <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- TA505445 3,000 Diesel 1994 <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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING. "I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 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 CALIF NIA' r <br /> APPLICANT'S SIGNATURE TITLE l' DATE�1 4e) <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) 7 i <br /> PLAN REVIEWER'S NAME .r DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST B /SLLTTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> r_ <br /> EH 23 046(REVISED 08/13199) Page 3 <br />