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SAN Y QUIN COUNTY PUBLIC HEALTP -r-RVICES <br /> ENVIRONMENTAL HEALTH DIVI9+104 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> fid REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#CAC002561188 I PROJECTCONTACT Keith A Tallia PHONE# 209-754-1808 <br /> FACILITY <br /> - - <br /> FACILITY NAME Stock PHONE# <br /> ADDRESS <br /> CROSS STREET Grant <br /> OWNEROPERATOR Raymond PHONE# 209-466-8604 <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME Oil Equipment Service PHONE# 209-754-1808 <br /> CONTRACTOR ADDRESS p CA LIC# CLASS A- Z <br /> INSURER State Comp WORKER COMP# 265057 <br /> FIREDISTRICT City Of Stockton PERMIT# <br /> LABORATORYNAME Argon Laboratory COUNTY SanJoa ui HONE# 209-581 -9280 <br /> SAMPLINGFIRM Condor Earth n 1 PHONE # 209-234-0518 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- 1000 Unknown Unknown <br /> 39- size esitmated-ma <br /> 39- differ upon removal) <br /> 39- <br /> ' 39- <br /> 139- <br /> Ar F� _klT <br /> 9- <br /> 39- <br /> 39-APF�G4NT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS.FEDERAL LAWS.AND RULES AND <br /> REG' -AT IONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING. 9 <br /> CERT,-Y THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY veh <br /> ERFwai <br /> THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LOR <br /> APPLICANT'S SIGNATURE TITLE Agent _DATE 1.128 O3_ <br /> . <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME�&� DATE-4— /)5—/y <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> E-1 23 045(RF V I$ED Oft/13/99) Page 3 <br />