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3' A N JOAQUIN Environmental Health Depattment <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 # PROJECT CONTACT Carrie Miller PHONE# (209) 461 -6337 <br /> FACILITY NAMEAG Spanos Aviation Dept PHONE # (209) 993-2481 <br /> ADDRESS Stockton CA 95206 <br /> CROSS STREET <br /> OWNER OPERATOR Thomas Tilley PHONE # (209) 993-2481 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Elite IV Contractors PHONE # (209) 461 ,-6337 <br /> CONTRACTOR ADDRESS 2535 Wigwam Dr Stockton CA 95205 CA LIC # 1001331 CLASS A <br /> INSURER Midwest Employers Casualty Company WORKER COMP# BNUWC0133392 <br /> FIRE DISTRICT Eire. 4i PERMIT # F A 1 ^ 3, <br /> LABORATORY NAME 0 COUNTY PHONE # <br /> SAMPLING FIRM PHONE # <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED <br /> 39 - Tank #3 20 , 000 Jet Aviation Fuel <br /> 39- Tank # 4 20 , 000 Jet Aviation Fuel <br /> 39- Tank # 5 121000 Jet Aviation Fuel <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 /> APPLICANT' S SIGNATURE i � TITLE Office Manager DATE 1 /24/23 <br /> ❑ APPROVED C] APPROVED WITH CONDITION ( S ) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME a`aaaaaatue DATE I 'L <br /> ANY DEVIATIONS FROM THIS AP LtCAATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS : <br /> 3of10 <br />