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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 : <br /> ❑ REMOVAL ❑ TEMPORARY CLOSURE ® CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # CAD000631507 PROJECTCONTACT Theresa Geier PHONE# 206 - 618 - 9061 <br /> FACILITYNAME Shell oil Products US - Stockton Terminal PHONE # 206 - 466 - 6941 <br /> ADDRESS 3515 Navy Dr , Stockton , CA <br /> CROSS STREET West Fyffe Street <br /> OWNER OPERATOR Shell oil Products US PHONE # 206 - 466 - 6941 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Wayne Perry Inc PHONE # 714 - 826 - 0325 <br /> CONTRACTOR ADDRESS 8281 Commonwealth Ave , Buena Park , CA 90621 CA LIC # 300345 CLASS <br /> INSURER Milestone Risk Management & Insurance Services WORKER COMP# CA10003737211 <br /> FIRE DISTRICT Stockton Port PERMIT # <br /> LABORATORY NAME Eurof ins Calscience COUNT6ran e IPHONE # <br /> SAMPLING FIRM Wayne Perry PHONE # 714 - 826 - 0325 <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39- 0121005 6000 Petroleum Contact Water 1988 <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 /> t ti <br /> i <br /> S <br /> . Scientist APPLICANT' S SIGNATURE TITLE SrDATE9 / 29 / 2021 <br /> ❑ APPROVED Ig APPROVED WITH CONDITION ( S ) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER' S NAME "44 DATE - v <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK, <br /> CONDITIONS : <br /> 3of10 <br />