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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> ❑ REMOVAL ❑ TEMPORARY CLOSURE CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT u cK UowdyPHONE#209-461-6337 <br /> FACILITYNAMESt.jose h's Medical Center I PHONE#209-461-6818 <br /> ADDRESS1800 Northa 1 orma Street, Stockton, 5 <br /> CROSS STREET C OU venue <br /> OWNER OPERATORSt.Jose h's Medical Center I PHONE# 209-461-6818 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Elite IV Contractors I PHONE#209-46 - <br /> 1333 7— <br /> CONTRACTOR ADDRESS 2 W m Drive CA LIC# 7 CLASS aZ <br /> INSURER x orer WORKER COMP#WPL500318-00 <br /> FIRE DISTRICT btocKton PERMIT# NA <br /> LABORATORYNAME GallechEnvironment5l COUNTY LA PHONE#562-272-2700 <br /> SAMPLING FIRM PHONE# <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39- NA piping diesel 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 SUBJECTT/O/1/WORKER'S COMPENSATION LAWS OF CALIFORNIA.' n �^ <br /> APPLICANT'S SIGNATUREYv TITLE <br /> ❑ APPROVED PPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE,CON DIWS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAM DATE4r'1 'L <br /> ANY DEVIATIONS FR IS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH23046 (Revised8/1/11) 3 <br />