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SAN JOAQUIN <br />-----COUNTY --- <br />Environmental Health Department <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 TANKS) EXPIRES 180 DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS, <br />INDICATE PERMIT TYPE: <br />13REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />,,,L, It , I Jill I I III,III o,N,l M.,.__ .,,.._ <br />FACILITY INFORMATION <br />EPA SITE #CAD982436735 PROJECT CONTACT Max Montgomery/Thompson Builders PHONE# 415456-8972 <br />FACILITY NAME SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES BUILDING PHONE # 209468113411 <br />ADDRESS 1601 E. HAZELTON AVE., STOCKTON CA <br />CROSS STREET HAZELTON AVE. & S. WILSON WAY <br />.OWNER OPERATOR SAN JOAQUIN COUNTY PHONE # 209468-3411 <br />I CONTRACTOR <br />CONTRACTOR NAME RB ENVIRONMENTAL INC <br />INFORMATION <br />PHONE # <br />209-932-0606 1 <br />CONTRACTOR ADDRESS 4460 HWY. 99 FRONTAGE ROAD, STOCKTON CA 95215 <br />I CA LIC # 747572 <br />DATE INSTALLED <br />I CLASS B -HAZ ] <br />INSURER SURETEC INSURANCE COMPANY <br />WORKER COMP# 9113854 EXP 10/01/2023 <br />] <br />FIRE DISTRICT STOCKTON <br />PERMIT # 23-0777 (Special Inspection -UST TANK REMOVAL) <br />LABORATORY NAME McCAMPBELL ANALYTICAL INC <br />COUNTY CONTRA COSTA] PHONE # <br />877'252'9262 ] <br />SAMPLING FIRM ADVANCEDGEO, INC <br />PHONE # 209467-1006 <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 W Rfl COMPENSATION LAWS OF CALIFORNIA." <br />p / 07/17/2023 <br />APPLICANT'S SIGNATURE ✓le �t.�.i TITLE DATE <br />TANK INFORMATION <br />TANK ID # <br />TANK SIZE <br />TANK CONTENTS PRESENT AND PAST) <br />DATE INSTALLED <br />39_ <br />500 GAL <br />UNKNOWN <br />UNKNOWN I <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 W Rfl COMPENSATION LAWS OF CALIFORNIA." <br />p / 07/17/2023 <br />APPLICANT'S SIGNATURE ✓le �t.�.i TITLE DATE <br />3of10 <br />❑ APPROVED 'C7 APPROVED WITH CONDITIONS) ❑DISAPPROVED <br />`" EE NDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME.I x__� DATE Y2 Z3 <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />3of10 <br />