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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE: <br /> ® REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT Robert Marty PHONE# (209)467-1006 <br /> FACILITY NAME Levand- fight roperty PHONE# 661 904-2133 <br /> ADDRESS 3 East Eleventh Street,Tracy, CA 95376 <br /> CROSS STREET East Holly Street <br /> OWNER OPERATOR Louis Levand Trust, Et. al. C/O Ms. Paula Levand PHONE# (661)904-2133 <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME Advanced GeoEnvironmental, Inc. PHONE# 209 467-1006 <br /> CONTRACTOR ADDRESS 837 Shaw Road, Stockton, CA 95215 CA LIC#680227 CLASS A-HAZ <br /> INSURER Travellers WORKER COMP# UB3338T982 <br /> FIRE DISTRICT City Or Tracy PERMIT# <br /> LABORATORY NAME Precision Enviro-Tech COUNTY San Joaquin I PHONE# (209)477-8105 <br /> SAMPLING FIRM Precision nviro- ec PHONE# (2U9)4 7-810 <br /> TANK INFORMATION <br /> TANKID# TANK SIZE TANK CONTENTS PRESENT AND PAST) DATE INSTALLED <br /> 39- 500-gallon Unknown4V2unknown <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE NTH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWNG: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT T/oVVQHKE/RR'S-COMPENSSATION�LAWS OF IFORNIA." <br /> APPLICANTS SIGNATURE(NIIPJAA l�2�k.+.+�-cwt J TITLE President PATE 01/03/14 <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITION ELOW AND/OR ON ATTACHMENT) /J�/���C( <br /> PLAN REVIEWER'S NAME DATED2ay/�" <br /> ANY DEVIATIONS FROM THIS APPLICATIO MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> /SPD SO�D��f��l�) � <br /> EH23046 (Revised3/I/Il) 3 <br />