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SANJOAQUIN 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 : Completed <br /> 9 REMOVAL 6/ 1991 ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # PROJECT CONTACTTom Bentz PHONE# 209-466-3003 <br /> FACILITY NAMEAssociated Tractor Service , Inc. PHONE # 209-466-3003 <br /> ADDRESS 1323 W. Charter Way, Stockton , CA 95206 <br /> CROSS STREETS , Stockton Street <br /> OWNER OPERATOR Associated Tractor Service , Inc. PHONE # 209-466-3003 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Was removed June 1991 - no contractor needed IPHONE # <br /> CONTRACTOR ADDRESS I CA LIC # CLASS <br /> INSURER WORKER COMP# <br /> FIRE DISTRICT PERMIT # <br /> LABORATORY NAME BC Laboratory COUNTY IPHONE # <br /> SAMPLING FIRM Ground Zero Analysis , Inc. PHONE # <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39 - 2527-01 1 , 000 - gallons gasoline unknown ( removed 6/1991 ) <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. " CONTRACTO ING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PE RMANCE OF THE WORK FOR WHICH THIS PE IT IS ISSUED , I SHALL <br /> E PERSONS SUBJECT TO WORKER'S PENSATION LAWS OF CA IF RNIA. " <br /> 7 <br /> Owner AT <br /> APPLICAN ATURE TITLE DATE <br /> ❑ APPROVED WAPPROVED WITH CONDITION ( S ) ❑ DISAPPROVED <br /> (SEE C NLSI ONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME t DATE <br /> 2§ <br /> ANY DEVIATIONS FROM THIS A Ll ATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS : <br /> 3of10 <br />