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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: EIREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE # PROJECT CONTACT Robert Marty PHONE# (209) 467-1006 FACILITY NAME Levand-Bright Property PHONE # 661 904-2133 ADDRESS 3 East Eleventh Street, Tracy, CA 95376 CROSS STREET East Holly Street OWNER OPERATOR Louis Levand Trust, Et. al. c/o Ms. Paula Levand T PHONE # (661) 904-2133 CONTRACTOR INFORMATION CONTRACTOR NAME Advanced GeoEnvironmental, Inc. I PHONE # 209 467-1006 CONTRACTOR ADDRESS 837 Shaw Road, Stockton, CA 95215 CA LIC # 680227 CLASS A-HAZ INSURER Travellers WORKER COMP# UB3338T982 FIRE DISTRICT City of Tracy PERMIT # LABORATORY NAME Precision Enviro-Tech COUNTY San Joaquin I PHONE # (209) 477-8105 SAMPLING FIRM Precision Enviro-Tech PHONE# 209 477-8105 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED 39_ 500 -gallon unknown unknown 39- 39- 39- 39- 39 - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: .I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WQaKER'S COMPENSATION LAWS OF LIFORNIA." APPLICANTS SIGNATURE TITLE President DATE 01/03/14 ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITION ELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATIO MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 8/1/11)