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Ao tJ I � 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 /> ❑ REMOVAL ❑ TEMPORARY CLOSURE ® CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # CAL 000334418 PROJECT CONTACT Ray Smith PHONE# 209 - 943 - 5662 ext . 5516 <br /> FACILITY NAME NuStar Terminals Operations Partnership L . P . PHONE # 209 - 943 - 5662 <br /> ADDRESS 3505 Navy Dr . <br /> CROSS STREET W . Fyffe St . <br /> OWNER OPERATOR Nustar Terminals 0 erations Partnershi L . P . PHONE # 209 - 943 - 5662 ext . 5516 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME WGR Southwest , Inc . PHONE # 310 - 629 - 5261 <br /> CONTRACTOR ADDRESS 11021 Winners Circle , Suite 101 CA LIC # 755455 CLASS B <br /> INSURER Security Nation Insurance Company WORKER COMP# SWC1268477 <br /> FIRE DISTRICT Los Alamitos „ CA 90720 PERMIT # <br /> LABORATORY NAME SunStar Anal tical Testimp, COUNTY Orange PHONE # 949 - 297 - 5020 <br /> SAMPLING FIRM WGR Southwest , Inc . PHONE # 310- 629 - 5261 <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED <br /> 39 - 10180861 - 001 6 , 000 gals . Other Petroleum ( Contact Waste Water ) 12 / 18 / 1987 <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: 01 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 Termina € Manager DATE 7114 / 2020 <br /> ❑ APPROVED ❑ APPROVED WITH CONDITION ( S ) ❑ DISAPPROVED <br /> ` SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> UA, <br /> PLAN REVIEWER'S NAME K - DATE # A , <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK, <br /> CONDITIONS : <br /> 3of10 <br />