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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EH 23 046 (Revised 7/10/92) Pape 3 <br />EPA SITE 0CAC000952600 <br />PROJECT CONTACT i TELEPHONE # Lou Tvedt 209-599-2347 <br />F <br />FACILITY NAME M. C. Liquors <br />PHONE # 209-944-5523 <br />C <br />ADDRESS 1628 Harbor Rd. Stockton, CA 95203 <br />1 <br />L <br />CROSS STREET Fresno Ave. <br />I <br />T <br />OWNER/OPERATOR <br />PHONE M <br />Y <br />Larry Johnson or Hardin <br />209-944-5523 <br />CONTRACTOR NAME paydirt Excavating Co. Inc. <br />PHONE #209-599-2347 <br />0 <br />N <br />CONTRACTOR ADDRESS 269 Oregon St. Ripon, CA 95366 <br />CA LID # 680679 <br />CLASS A & Haz. <br />T <br />R <br />INSURER National American Ins. Co, of CA <br />WORK.COMP.#FR WC2 0011206D <br />A <br />C <br />FIRE DISTRICT Stockton City Fire District <br />PERMIT # <br />T <br />0*"ORATORY <br />NAME Sherwood Laboratory <br />PHONE # 209-667-5259 <br />R <br />SAMPLING FIRM Del - Tech Ll� PHONE # 209-847-8757 <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />TANKI <br />39- <br />T <br />39- -w <br />10 Onn gyllnn <br />A <br />39- <br />N <br />39- <br />10,00n gyallnn _ _ <br />ga enl; no <br />' <br />K <br />39- <br />39- <br />-- iiii � r rmmmmmnnr <br />L / APPROV D: ROVED WITH CONDITION(S) DISAPPROVED <br />p ( -'A ACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />�J��T�YY 4 r� /tjt <br />��Itt1111111111111111F11F <br />rF�Y7C��FT Y�R�►S�tYTtiit�YYYYTTi7iii� <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CCURTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA. - <br />,` �''"t ��- <br />APPLICANT'S SIGNATURE: 7 Z' G \.� TITLE DATE <br />EH 23 046 (Revised 7/10/92) Pape 3 <br />