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SANA N JOAQUIN <br /> 0 n Q U( N Environmental Flealth Department <br /> -H-IC O U NHT�jY---- <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 PHONE# 209-933-7045 <br /> FACILITY NAME SUSD-WEBER INSTITUTE PHONE# 209-933-7045 <br /> ADDRESS 302 WEST WEBER AVENUE <br /> CROSS STREET NORTH MADISON STREET <br /> OWNER OPERATOR STOCKTON UNIFIED SCHOOL DISTRICT PHONE# 209-933-7045 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME RB ENVIRONMENTAL,INC. PHONE# 209-932-0606 <br /> CONTRACTOR ADDRESS 4460 HWY 99 FRONTAGE ROAD,STOCKTON,CA CA LIC# 747572 CLASS B-HAZ <br /> INSURER STATE COMPENSATION INSURANCE FUND WORKER COMP#9113854 <br /> FIRE DISTRICT STOCKTON PERMIT# i?OS 2r -•C� % <br /> LABORATORY NAME MCCAMPBELL ANALYTICAL COUNTY CONTA COSTA PHONE# 877-252-9262 <br /> SAMPLING FIRM ADVANCEDGEO INC. PHONE# - - <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED <br /> 39- 001 1,100 GALLONS UNKNOWN FUEL UNKNOWN <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 /> APPLICANT'S SIGNATURE ! / TITLE DATE t 11�� `'® <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE-� 5 �26 <br /> ANY DEVIATIONS FROM HI, APPLIC ION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> 3of10 <br />