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SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS <br /> SUBSTANCES STORAGE TANK(S ) EXPIRES 180 DAYS FROM THE APPROVAL DATE , DO NOT WRITE IN ANY SHADED AREAS . <br /> INDICATE PERMIT TYPE: <br /> 13REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # PROJECT CONTACT John Bubica PHONE# 209 - 625 - 5261 <br /> FACILITY NAME DBL Rentals PHONE # 209 - 625 - 5261 <br /> ADDRESS 619 and 625 North Sacramento Street <br /> CROSS STREET West S urce Street <br /> OWNER OPERATOR John Bubica PHONE # 209 - 625 - 5261 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Valued En ineerin - James Cornell PHONE # 209 -477 - 4500 <br /> CONTRACTOR ADDRESS 10409 Lonestar Way CA LIC # 745200 CLASS A - Haz <br /> INSURER BC Environmental Brookers WORKER COMP# FEI -ECC- 19188 - 05 <br /> FIRE DISTRICT Lodi PERMIT # _ <br /> LABORATORY NAME EnviroChem Inc. COUNTY LOS An eles PHONE # 909 - 590 - 5905 <br /> SAMPLING FIRM Advanced GeoEnvionmenta Inc . PHONE # 209 -46 - 1006 <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39_ 5209614500 Gasoline 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 C PENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE TITLE 1211*4"� DATE 09 - 30 - 19 <br /> oe Lo� role ro� <br /> �L <br /> ❑ APPROVED E APPROVED WITH CONDITION (S ) ❑ DISAPPROVED <br /> (SEE CON TIONS BELOW AND/OR ON ATTACHMENT) C� <br /> PLAN REVIEWER' S NAME cu ) j DATE[ <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS : <br /> 3of10 <br />