Laserfiche WebLink
-(-1 <br />fTl <br />6--T3 <br />:s{�0� s fliGrji i �:C.'• • � •- �Jilders a . _ - <br />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 />im CC11All\/AI n TGMPr)PAPV r1l O.RIIRF fl CLOSURE IN PLACE <br />FACILITY INFORMATION <br />TANK INFORMATION <br />EPA SITE # PROJECT CONTACT Robert Marty <br />PHONE# (209) 467-1006 <br />FACILITY NAME Levand Property <br />PHONE # (202) 342-2277 <br />ADDRESS 47 East Eleventh Street, Tracy, CA 95376 <br />500 -gallon JYkGI-w4*mawn-fuel (gasoline/diesel} <br />CROSS STREET East Portal Street <br />v7A <br />OWNER OPERATOR Levand Family Trust c/o Paula Levand <br />PHONE # (202) 342-2277 <br />CONTRACTOR INFORMATION <br />CONTRACTOR NAME Advanced GeoEnviron mental, 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 Of Tracy PERMIT # <br />LABORATORY NAME Precision Enviro-Tech COUNTY San Joaquin PHONE # (209) 477-8105 <br />SAMPLING FIRM Precision Enviro-Tech I PHONE # 209 477-8105 <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 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />EMPLOY PERSONS SUBJECT TO WORKEW COMPfNSATM�J LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE <br />TITLE President <br />TE 09/17/13 <br />❑ APPROVED APPROVED WITH CONDITION(S) 1-1 DISAPPROVED <br />(SEE CONDITI. NS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME %�-� DATE � �r <br />ANY DEVIATIONS FROM THIS APPLICATI N MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />EH 23 046 (Revised 8/1/11) <br />3 <br />TANK INFORMATION <br />TANK ID # <br />TANK SIZE TANK CONTENTS PRESENT AND PAS <br />DATE INSTALLED <br />39- 520 <br />500 -gallon JYkGI-w4*mawn-fuel (gasoline/diesel} <br />unknown <br />v7A <br />39- �_ _-) <br />k6'6 <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 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />EMPLOY PERSONS SUBJECT TO WORKEW COMPfNSATM�J LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE <br />TITLE President <br />TE 09/17/13 <br />❑ APPROVED APPROVED WITH CONDITION(S) 1-1 DISAPPROVED <br />(SEE CONDITI. NS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME %�-� DATE � �r <br />ANY DEVIATIONS FROM THIS APPLICATI N MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />EH 23 046 (Revised 8/1/11) <br />3 <br />