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SFN O H Q u I N Environmental Health Department <br /> COUNTY <br /> �Y <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT FNV11 ; UNN/IENTAL HEALTH <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOU`'' AAENT <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 # CAR000269274 PROJECT CONTACT Daryl Lee, Retail Compliance Coord . PHONE# 415 902- 5089 <br /> FACILITY NAME ARCO amipm Fuel Facility FAC #7049 PHONE # 209 334=3678 <br /> ADDRESS 800 East Kettleman Lane, Lodi CA 95240 <br /> CROSS STREET CA Highway 99 <br /> OWNER OPERATOR BP West Coast Products, LLC PHONE # (360) 371m1500 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Town & Country Contractors Inc . PHONE # 916 636 .9500 <br /> CONTRACTOR ADDRESS 3206 Luyung Drive, Rancho Cordova, CA 95742 CA LIC # 238112 CLASS A, B HAZ <br /> INSURER State Compensation Fund WORKER COMP# 921878218 <br /> FIRE DISTRICT City of Lodi , CA PERMIT # F02019.591 <br /> LABORATORY NAME Eurofins TestAmerica COUNTY Orange PHONE # (949) 261 =1022 <br /> SAMPLING FIRM Antea Group PHONE # 800 477 .7411 <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39- 10339507 .001 10, 000 Regular Unleaded Gasoline 11111992 <br /> 39- 10339507.002 10, 000 Regular Unleaded Gasoline 11111992 <br /> 39- 10339507-003 10,000 Regular Unleaded Gasoline 11111992 <br /> 39- 10339507.004 10,000 Premium Unleaded Gasoline 11111992 <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 WO KSWS�G SATION LAWS OF CAL (FORNIA. ' CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING ERTIFY AT"IN :ijjF..PEP. FORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WO KtR 'S COP APd SOF CALIFORNIA.' <br /> APPLICANT' S S►GNATU TITLE _�L f J DATE <br /> ❑ APPROVED APPROVED WITH CONDITION ( S ) ❑ DISAPPROVED <br /> /SEE <br /> � CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> � � Y VAy <br /> PLAN REVIEWER'S NAME N 1.��� DATE b `3lrl <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS : <br /> 3of10 <br />