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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 O CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# C DD PROJECT CONTACT Mr Walter Hocutt I PHONE#(650)689-5073 <br /> ' FACILITY NAME Walgreens IPHONE# <br /> ADDRESS Northeast corner of Farmington Road and East Mariposa Road Stockton.CA 95025 <br /> CROSS STREET East Mariposa Road <br /> ' OWNER OPERATOR WalgreensPHONE#1650)689-5073 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAMEAII Chemical Disposal Inc. IPHONE#(408)363-1660 <br /> ' CONTRACTOR ADDRESS 21 Great oaks Blvd.San Jose,CA CA LIC#599884 <br /> CLASS HAZ 8 General <br /> WORKER COMP#93773a4-07 <br /> INSURER American Zurich Insurance Company <br /> FIRE DISTRICT Stucklon Fire Deparlmenl PERMIT# <br /> ' LABORATORY NAME SunStar Laboratories.Inc, COUNTY Orange PHONE D49-297-5020 <br /> SAMPLING FIRMPs. PHONE#si"a o <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED <br /> I 39- p 5 Z64 3?' 1000 gallon Past-Diesel Fuel Unknown <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT <br /> 9- <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 AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE <br /> FOLLOWING: '1 CERTIFY THAT IN THE PE NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON N SUCH <br /> A MANNER AS TO BECOME SUB ITERS-89MP;NSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE G: 'I CERTIFY THAT IN7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED I SHALL <br /> EMPLOY PERSONS SUB)tiCY TO 'S COMPENSATION LAS OF CALIFORNIA.- <br /> APPLICANT'S <br /> ALIFORNIA-APPLICANT'S SIGNATURE TITLE1•r'Tr f'C' DATE IC Ltd O <br /> ❑ APPROVED JKAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> ( E ONDITIONS BEL W A ON ATTACHMENT) <br /> ' PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM T S APPL CATI MUST BE$UBMIE 0 EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDI ONS: <br /> HH 23 046 (Revised 8/1/1 1) 3 <br />