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4 - w w p 1"� e RECEIVED ENVIRONMENTAL HEALTH DEPARTMEW ""' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH APPLICATION FOR UNDERGROUND STORAGE TANDEPARTMENT CLOSURE PERMIT THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: IS REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE # I PROJECT CONTACT Terry,D. Hamilton I PHONE# 209 404-7700 FACILITY NAME Residence of Rodney D. Gaede and Linda D. Gaede PHONE # 209 639-7012 ADDRESS 8476 E. Kettleman Lane, Lodi CA 95240 CROSS STREET Alpine Rodd OWNER OPERATOR NIA PHONE # NIA CONTRACTOR INFORMATION CONTRACTOR NAME Terry D. Hamilton I PHONE # (209) 404-7700 CONTRACTOR ADDRESS 1502 Westbrook Court Modesto CA 95358 CA LIC # 339108 CLASS A B C HAZ INSURER State Compensation Insurance Fund WORKER COMP# 9047473-16 FIRE DISTRICT Mokelumne Fire District PERMIT # Done Will notify Fire Chief. He's not sure if he'll LABORATORY NAME ICOUNTYtZCr)� PHONE# SAMPLING FIRM nvironmenta Compliance roup PHONE # (209)664-1035 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWWNG: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FCLLOWING; "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' APPLICANT'S SIGNATURE TITLE Contractor DATE 11!712016 ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED O EHD FOR APPROVAL ERIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 7/26/20[6) 3 visit site) TANK INFORMATION TANK 1D # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED 39-001 350 -Gallon Empty/Gasoline On or about 1964 39- 39- 39- 39- 39 - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWWNG: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FCLLOWING; "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' APPLICANT'S SIGNATURE TITLE Contractor DATE 11!712016 ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED O EHD FOR APPROVAL ERIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 7/26/20[6) 3 visit site)