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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 1BO 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#CAC00267B515 PROJECT CONTACT Mc Waller Hocun <br /> FACILITY NAME Walgreens PHONE#(650)689-5073 <br /> PHONE# <br /> ADDRESS Northeast comer of Farmington Road and East Madposa Road Stockton,CA 95025 <br /> CROSS STREET East Madposa Road <br /> OWNER OPERATOR Walgreens <br /> PHONE#(850)689-5073 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME All Chemical Disposal,Inc. IPHONE#(408)363-1660 <br /> CONTRACTOR ADDRESS 21 Great Oaks Blvd.San Jose,CA CA LIC 099664 7 CLASS HAZ 8 General <br /> INSURER American Zurich Insurance Company WORKER COMP#9377344-07 <br /> FIRE DISTRICT Stockton Fins Department PERMIT# <br /> LABORATORY NAME SunStar Laboratories,Inc. COUNTY Orange PHONE#949-297-5020 <br /> SAMPLING FIRM Psi PHONE#si.xs <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39 1(000 gallon Past-Diesel Fuel Unknown <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 D <br /> AN <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TH <br /> FOLLOWING. '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCEH <br /> A MANNER AS T BECOME SUBJECT TO;TNORKERS COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE F KO 'p�Y THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJ O W ER'S COMPS LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE —� .TITLEf;FtDATE f 0ZS <br /> DA PROVED PPROVED WITH CONDITIONS) ❑ DISAPPROVED <br /> E ONDITIONS 8 OW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME N�_ <br /> �an� 4'A�pATE—� "_ <br /> ANY DEVIATIONS FROM HIS A L AT MUST BE SU MITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> DITIONS: <br /> C : <br /> EH 23 046 (Revised 8%1(11) 3 <br />