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0 • r- e�* r-.-. `,""j" rr ENVIRONMENTAL HEALTH DEPAt , SAN JOAQUIN COUNTY AUG , 207 APPLICATION FOR UNDERGROUND STORAGI;FNTMKMENT/AL HEALTH CLOSURE PERMIT DEPARTMENT 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: ® REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE CONTRACTOR INFORMATION CONTRACTOR NAME B&T Service Station Contractors I PHONE # 805-929-8944 ext 1002 CONTRACTOR ADDRESS 630 South Frontage Road, Nipomo, CA 93444 CA LIC # 902034 1 CLASS A,B,C-61/D-4 INSURER State Compensation Insurance Fund of California WORKER COMP# 90685282016 FIRE DISTRICT Waterloo Morada PERMIT # LABORATORY NAME California Laboratory Services COUNTY Sacramento IPHONE# 800-638-7301 SAMPLING FIRM Apex Envirotech PHONE# 916-851-0174 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED 39- TA0515660 12,000 gallon Motor Vehicle Fuel 12-20-2002 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE `i{ 4'� Pa""4`�" TITLE Project Coordinator DATE 8/25/2017 ❑ APPROVED XAPPROVED WITH CONDITION(S) ❑ DISAPPROVED (GEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME / ril DATE II(P / 1-7 ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 7/26/2016) FACILITY INFORMATION EPA SITE # PROJECT CONTACT Beth DePaola PHONE# 916-843-3817 FACILITY NAME California Highway Patrol #265 PHONE # 916-843-3806 ADDRESS 3330 North Ad Art Road, Stockton, CA 95215 CROSS STREET Cherokee Road OWNER OPERATOR California Highway Patrol PHONE # 916-843-3806 CONTRACTOR INFORMATION CONTRACTOR NAME B&T Service Station Contractors I PHONE # 805-929-8944 ext 1002 CONTRACTOR ADDRESS 630 South Frontage Road, Nipomo, CA 93444 CA LIC # 902034 1 CLASS A,B,C-61/D-4 INSURER State Compensation Insurance Fund of California WORKER COMP# 90685282016 FIRE DISTRICT Waterloo Morada PERMIT # LABORATORY NAME California Laboratory Services COUNTY Sacramento IPHONE# 800-638-7301 SAMPLING FIRM Apex Envirotech PHONE# 916-851-0174 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED 39- TA0515660 12,000 gallon Motor Vehicle Fuel 12-20-2002 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE `i{ 4'� Pa""4`�" TITLE Project Coordinator DATE 8/25/2017 ❑ APPROVED XAPPROVED WITH CONDITION(S) ❑ DISAPPROVED (GEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME / ril DATE II(P / 1-7 ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046 (Revised 7/26/2016)