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0 i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PER MANE NT/TEM PORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANC <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT T E: <br /> QREMOVAL ❑ TEMPORARY CLOSURE FE- CLOSURE IN PLAC <br /> FACILITY INFORMATION <br /> EPA SITE# PRO,JEC CONTACT Mr.Walter Hocutt <br /> PHONE#(650)s8s-Sa73 <br /> FACILITY NAME Walgreens <br /> PHONE# <br /> A RESS Northeast corner of Farmington Roa nd East Mariposa Road Stockton,CA 95025 <br /> CROSS T East Mariposa Road <br /> OWNER OPERATOR Walgreens <br /> PHONE#(65o)) 89-5073 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME All Chemical Disposal,Inc. <br /> PHON #(408)363-1660 <br /> CONTRACTOR ADDRESS 21 Great Oaks Blvd.San Jose,CA CA LIC#599864 Z CLASS HAZ&General <br /> INSURER American Zurich Insurance Company WORKER COMP#9377344-07 <br /> FIRE DISTRICT Stockton Fire Department PERMIT# <br /> LABORATORY NAME SunStar Lahoratories,Inc. COUNTY Orange PHONE#949-297-5020 <br /> SAMPLING FIRM Psi PHONE#51 o-434-9IDQ <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT D PAST) DATE INSTALLED <br /> 39- 1000 gallon Past-Diesel Fu Unknown <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> ZD 1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN J AQUIN COUNTY ORDINANCES,STATE LAWS, FEDERAL LAWS, ND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERF NQEL HE WO FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUB � CO N LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES TSI LOWING: RTIFY THS E RFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS JECT TO WOR SCO 1Sft"fT©N WS ALIFORNIA." <br /> APPLICANT'S 13IGNATUR TITLE DATE <br /> El APPROVEDAPPROVED WITH CONDITION(S) Q DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM TH APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> E11 23 046 (Revised 8/l l l 1) 3 <br />