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SANJOAQUIN Environmental Health Department <br /> - - COUNTY -- <br /> APPLICATION <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 PROJECT CONTACT 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 /> OWNEROPERATOR Shell Oil Products US PHONE # 206 - 466 - 6941 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Wayne Perry Inc PHONE # 714 - 826 - 0325 <br /> 1111 ,11 <br /> CONTRACTOR ADDRESS 8281 Commonwealth Ave , Buena Park , CA 90621 CA LIC # 300345 1 CLASS ' <br /> INSURER Milestone Risk Management & Insurance Services WORKER COMP# CA10003737211 <br /> FIRE DISTRICT Stockton Port PERMIT # <br /> LABORATORY NAME Test America COUNTY IPHONE # <br /> SAMPLINGFIRM Wayne Perry PHONE # 714 - 826 - 0325 <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAS 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 /> 6UIc4 � 45z a e" <br /> APPLICANT'S SIGNATURE `� TITLE Sr . Scientist DATE <br /> 6 . 10 . 21 <br /> ❑ APPROVED M APPROVED WITH CONDITION ( S ) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> I ` <br /> PLAN REVIEWER'S NAME G-2 _ DATE < C/ <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK, <br /> CONDITIONS : <br /> 3of10 <br /> II <br /> I <br />