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ENVIRONMENTAL HEALTH DEPARpf. <br /> TI* <br /> NEL) <br /> SAN JOAQUIN COUNTY SEP 15 2015 <br /> APPLICATION FOR UNDERGROUND STORAGE TPMIRONMENTAL <br /> CLOSURE PERMIT NFQITunGooRTAAI`NT <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 COS - 800 East Main PHONE# 209 937-8374 <br /> ADDRESS 800 East Main Street, Stockton, CA <br /> CROSS STREET Grant Street <br /> OWNER OPERATOR CIt of Stockton PHONE# 209 937-8374 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME 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 of Stockton PERMIT# TBD <br /> LABORATORY NAME Preclon Enviro-Tech COUNTY San Joaquin I PHONE# 209 477-8105 <br /> SAMPLING FIRM Precision Enviro-Tech PHONE# ( 09)477-8105 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST) DATE INSTALLED <br /> 39- 500-gallon Unknown 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 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." r <br /> APPLICANT'S SIGNATURE TITLE President DATE <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME 04 DATE `A <br /> t S <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046 (Revised 07/17/14) 3 <br />