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SAN ,,.)AQUIN COUNTY PUBLIC HEAL- SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <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 /> f7 REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT bill little PHONE -1 nor <br /> FACILITYNAME Silveria Property PHONE# _ <br /> ADDRESS 1933 Haiwatha Avenue stockton ca 95205 <br /> CROSS STREET <br /> OWNEROPERATOR PHONE#209 467-8320 INFORMATION <br /> CONTRACTOR NAME Advanced Geo Envir PHONE467-IU 6 <br /> CONTRACTOR ADDRESS 837 Shaw Road Stockton95215 CALK CLASS <br /> INSURER saint paul / state fund WORKERCOMP# 1317474-27 Stockton PERMIT# on-file <br /> LABORATORYNAME Preclsloon E tech COUNTY SiPHONE# 462-0892 <br /> SAMPLING FIRM same PHONE # 462-0892 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS JPRESENT& PAST DATE INSTALLED <br /> 39- 500 gal cfasoline unkown <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: '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 FOLLOWIAG: '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.' <br /> APPLICANT'S SIGNATURE (^ Uiyi�� SITLE ' �� DATE <br /> ❑ APPROVED ^APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME - 9-qfazt- DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> r <br /> %e v <br /> EH 23 046(REVISED 08113199) Page 3 <br />