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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PEkNffr <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANOCNMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE : CAC0p 15O I PROJECT CONTACT 8 TELEPHONE Tim Cuellar 209-95600264 <br /> F FACILITY NAME Cityof Stockton parkinglot PHONE 'W No phone <br /> A <br /> C ADDRESS American St. and Washington St. <br /> I <br /> L CROSS STREET an Washington St. <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y City of Stockton c/o Mr. George Chen 209-937-8411 <br /> C CONTRACTOR NAME Advanced GeoEnvironmental, Inc. PHONE X 209-956-0264 <br /> 0 <br /> N CCNTRACTOR ADDRESS 1803 W. March Lane #A CA LIC * 680227 I CLASS A <br /> T <br /> R INSURER Acord - Dealey, Renton & Assoc. WORK.CCMP.i 1317474-95 <br /> A <br /> C FIRE DISTRICT Stockton Fire Department I PERMIT <br /> T <br /> 0 LABORATORY NAME Mc Campbell Analy. I COUNTY Contra Costa PHONE 9 1 -510-798-1620 <br /> R <br /> SAMPLING FIRM McCambell Analy. I PHONE # 1 -510-798-1620 <br /> I I I I I I I I I I 11111111111111111 f11 <br /> TANK ID Z TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- rw• Lt�.DO i _ �_ _Al <br /> T 39- I,F-C1l1G ;Cl <br /> A 39- <br /> 1 N 39- <br /> K 39- <br /> 39- <br /> 39 <br /> P <br /> IIII11111111111111111111111111 Illlllillllllllllllllllllllliltl II IIIIIillllllllllilllllllllilll lIII1111111111�11111111 <br /> L APPROVED APPROVED WITH CONDITICN(S) DISAPPROVED <br /> A ( E^ CONDITIONS 3ELOW AND/OR ON ATTACHMERT) <br /> N PLAN REVIEWER'S NAME D Q1lQI DATE <br /> IIfill III I I1111111111111tI 11111111111111111111111111 alai IIIIIIIIl111111IIiilllllilllllllllllllltll 11111111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACUIN CCUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JCACUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLCWING: 1-1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WCRKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." 1n- <br /> APPLICANT'S SIGNATURE: :] ""`� Y7!^, . U.Q,� TITLE Geelo IST DATE 1-30-41 <br /> CONDITION(S): <br /> b4Aa&e, m r <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />