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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 /> EIREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT Robert Marty PHONE# (209)467-1006 <br /> FACILITY NAME Levand-Bright Property 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 Levan d 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#6802271 CLASS A-HAZ <br /> INSURER Travellers WORKER COMP# UB3338T982 <br /> FIRE DISTRICT Clty Of I raCy PERMIT# <br /> LABORATORY NAME Precision Enviro-Tech COUNTY San Joaquin PHONE# (209)477-8105 <br /> SAMPLING FIRM Precision Enviro- ech PHONE# 09 477-51 0 <br /> TANK INFORMATION <br /> TANKID# TANK SIZE TANK CONTENTS PRESENT AND PAS DATEINSTALLED <br /> 39- 500-gallon unknown fuel (gasoline/diesel) 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 ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S 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 FOLLOWING: 'I CERIIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKERS <br /> �COMPENSATION <br /> �LAWS OF�'�QA!LyLIFFO,R_NIA.' <br /> APPLICANTS SIGNATURE ��^"' - -�r'i`(� I '_ IlTLE President DATE 01/03/14 <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 /> EH 23 046 (Revised 8/l/11) 3 <br />