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ENVIRONMENTAL HEALTH DAVARTMENT <br />SAN JOAQUIN COUNTY <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 />a REMOVAL <br />EPA SITE # CAC002625567 <br />FACILITY NAME Haight Ro <br />ADDRESS 642 <br />CROSS STREET <br />OWNER OPERATOR <br />CONTRACTO <br />CONTRACTOR ADDRESS <br />INSURER State <br />FIRE DISTRICT <br />LABORATORY NAME <br />SAMPLING FIRM Ne] <br />❑ TEMPORARY CLOSURE <br />FACILITY INFORMATION <br />PROJECT CONTACT Jaynes Robinson <br />1 Tank Removal Proiect, APN 061-150- <br />E. Haight Road. Lodi, CA 95240 <br />Curry Avenue <br />Hondo Comnanv I <br />CLOSURE IN PLACE <br />PHONE# 1L71j",v,, <br />PHONE # (209) 367-21 <br />PHONE # (209) 369-8255 <br />CONTRACTOR INFORMATION <br />D & S Drap-line Service 7PHONE# 209-587-1609 <br />540 F Street, Los Banos, CA CA LIC # 653321 CLASS A - Haz <br />tion Insurance Fund WORKER COMP# 238-0000625 <br />okelumne PERMIT # currently being processed <br />)n Laboratorle5 COUNTY Stanislaus I PHONE# 209-581-9280 <br />rann-notatP.c_ Inc_ PHONE # <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 W MPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNAT RE TITLE DATE <br />❑ APPROVED ❑ APPROVED WITH CONDITIONS) ❑ DISAPPROVED <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME DATE <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />EH 23 046 (Revised 8/3/07) 3 <br />