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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 [29 CLOSURE IN PLACE <br />FACILITY INFORMATION <br />EPA SITE # PROJECT CONTACT PAVt L� �"X�l�/ /F�fF PHONE# 9.01 L.17(" 5 -WO <br />FACILITY NAME Kaiser Permanente PHONE # 209-476-5408 <br />ADDRESS 7373 West Lane, Stockton, CA, 95210 <br />CROSS STREET Hammertown Drive <br />OWNER OPERATOR Kaiser Permanente PHONE # 209-476-5408 <br />CONTRACTOR INFORMATION <br />CONTRACTOR NAME Elite IV Contractors <br />I PHONE #209-461-6337 <br />CONTRACTOR ADDRESS 2535 Wi wam Drive <br />CA LIC # <br />660076 CLASS A Haz <br />INSURER Explorer <br />WORKER COMP# WPL <br />1 - <br />500318-00 <br />FIRE DISTRICT Stockton <br />FIRE <br />PERMIT # <br />LABORATORY NAME CalTechEnvironmental <br />COUNTY LA <br />f PHONE # 562-272-2700 <br />SAMPLING FIRM AdvancedGeoEnvironmental Inc. <br />PHONE # 209-467-1006 <br />TANK INFORMATION <br />TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br />39- NA piping diesel fuel 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." <br />APPLICANT'S SIGNATURE 57C I C) TITLE /%I � DATE <br />❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />(SE <br />�NDITIS BELOW AND/OR ON ATTACHMENT)PLAN REVIEWER'S NAM % � DATE (Z-7 <br />ANY DEVIATIONS FRONT THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />EH 23 046 (Revised 8/1/11) <br />