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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY 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 S6 D/ PROJECT CONTACT Kathryn Garcia PHONE# 209-333-6740 <br /> FACILITY NAME City of Lodi Municipal Service Center PHONE# 209-333-6740 <br /> ADDRESS 1331 S. Ham Lane Lodi CA 95242 <br /> CROSS STREET Kettleman Lane <br /> OWNER OPERATOR City of Lodi PHONE# 209-333-6800 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME t✓/ •11e . IPHONE# 2c< <br /> CONTRACTOR ADDRESS t' Le-1,/ C CA LIC# 9 5,(3;`/ CLASS A 11,Y L <br /> INSURER 4E/c 44,%) WORKER COMP# <br /> FIRE DISTRICT C 1 T 4 j. Z-001 PERMIT# <br /> LABORATORY NAME Geoanalytical Laboratories COUNTY PHONE# c 66,9010a <br /> SAMPLING FIRM S11414c PHONE# ZQ 9 46 46 9 0 / <br /> Lodi TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED <br /> 39- 2000 gallons Waste Oil 1989 <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 COMPENSATIO I LA OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE c.- `' TITLE Compliance Engineer DATE �� it <br /> ❑ APPROVED �VAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> CON BELOW AND/OR ON ATTACHMENT) <br /> ,. <br /> A�x <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 07/22/10) 3 <br />