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SAN 10AQUIN ----- C O U N T Y �- --- Environmental Health Department 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: -9 REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE TANK INFORMATION FACILITY INFORMATION EPA SITE # TANK CONTENTS PRESENT AND PAS PROJECT CONTACT 77 PHONE# 209-933-7045 FACILITY NAME SUSD-WEBER INSTITUTE PHONE # 209-933-7045 ADDRESS 302 WEST WEBER AVENUE CROSS STREET NORTH MADISON STREET OWNER OPERATOR STOCKTON UNIFIED SCHOOL DISTRICT PHONE # 209-933-7045 TANK INFORMATION CONTRACTOR INFORMATION TANK SIZE TANK CONTENTS PRESENT AND PAS CONTRACTOR NAME RB ENVIRONMENTAL, INC. 1,100 GALLONS UNKNOWN FUEL I PHONE # 209-932-0606 CONTRACTOR ADDRESS 4460 HWY 99 FRONTAGE ROAD, STOCKTON, CA ANY DEVIATIONS FROM HI APPLIC ION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS. CA LIC # 747572 CLASS B-HAZ INSURER STATE COMPENSATION INSURANCE FUND WORKER COMP#9113854 T STOCKTON PERMIT # i?�3S ZrjY M NAME MCCAMPBELL ANALYTICAL COUNTY CONTA COSTA PHONE# 877-252-9262 RM ADVANCEDGEO INC. PHONE # - - TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED 39_ 001 1,100 GALLONS UNKNOWN FUEL UNKNOWN 39- ANY DEVIATIONS FROM HI APPLIC ION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS. 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: 601 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'S TITLE 1�l UL ��Si�l't-ALV DATE' 3of10 ❑ APPROVED APPROVED WITH CONDITIONS) ❑DISAPPROVED / (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAM DATE �> 5 ANY DEVIATIONS FROM HI APPLIC ION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS. 3of10