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SANJOAQUIN Environmental Health Department <br /> -- COUNTY <br /> f y } rM <br /> APPLICATION FOR UNDERGROUND STORAGE TANK IVIA 3 1 2020 <br /> CLOSURE PERMIT <br /> FSIVIR0NMFNTAL HEALTH <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS " hENT <br /> SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE , DO NOT WRITE IN ANY SHADED AREAS . - <br /> INDICATE PERMIT TYPE: <br /> ® REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # PROJECT CONTACT Matt Thomas PHONE# 626 -627-8316 <br /> FACILITY NAME DPIF2 CA Army Court LLC IPHONE # 775-858 - 8080 <br /> ADDRESS 1624 Army Court Stockton <br /> CROSS STREET West Charter Way <br /> OWNER OPERATOR DPIF2 CA JPHONE # 775-858-8080 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME CGRS , Inc. PHONE * 916- 991 - 1100 <br /> CONTRACTOR ADDRESS 5444 Dry Creek Road I CA LIC # 803616 CLASS A/C61 /D40/D63/HA <br /> INSURER Zurich American Zurch American WORKER COMP# WC 4632690 <br /> FIRE DISTRICT City of Stockton PERMIT # <br /> LABORATORY NAME Pace Analytical Services LLC . COUNTY PHONE # <br /> SAMPLING FIRM A , E . COM PHONE # 610-234-5151 <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39 - T1 10 , 000 diesel unk <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. " <br /> APPLICANT'S SIGNATURE ( TITLE Compliance Service Manager DATE 3-30-20 <br /> ❑ APPROVED 9APPROVED WITH CONDITION (S ) ❑ DISAPPROVED <br /> (SEE C DITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER' S NAME L DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS : <br /> 3of10 <br />