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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 180 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# PROJECT CONTACTMr.Walter HOouII PHONE#(650)689-5073 <br /> FACILITY NAME Walgreens PHONE# <br /> ADDRESS Northeast corner of Farmington Road and East Mariposa Road Stockton,CA 95025 <br /> CROSS STREET East Mariposa Road <br /> OWNER OPERATOR Walgreens PHONE# 50)689-5073 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME All Chemical Disposal,Inc. I P NE#(408)363-1660 <br /> CONTRACTOR ADDRESS 21 Great Oaks Blvd.San Jose,CA CA LIC#599§64 CLASS HAZ&General <br /> INSURER American Zurich Insurance Company WORKER COMP#9377344-0 <br /> FIRE DISTRICT Stockton Fire Department PERMIT# <br /> LABORATORY NAME SunStar Laboratories,Inc. COUNTY Orange PHONE#949-297-5020 <br /> SAMPLING FIRM Psi PHONE 451eaw200 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT ND PAS DATE INSTALLED <br /> 1 <br /> 39-bYLOLI 1000 gallon Past-Diesel Fu Unknown <br /> 39 31 <br /> - <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JO LIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PE ANCE OF THE WORK R WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUB RER'S-66MP NSAjTION LAWS OF CALIFORNIA- CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE NG: 'I CERTIFY THAT IN ME PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUB T '�COMPENSAT�IONS CALIFORNIA.'^u <br /> APPLICANT'S SIGNATURE TITLE `i� -� C DATE tO Zt� II <br /> ❑ APPROVED 0 APP OVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE COINDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046 (Revised 8/1/11) 3 <br />