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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 4/26/94) Page 3 <br />EPA SITE #CAC001081776 <br />PROJECT CONTACT & TELEPHONE #Gur al Sldhu 209-466-5816 <br />F <br />A209-466-5816 <br />FACILITY NAME Waterloo Food & Fuel <br />PHONE # <br />C <br />1 <br />ADDRESS 3032 E. Waterloo Rd., Stockton, CA 95205 <br />L <br />I <br />CROSS STREET Sutro <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />CO <br />I CONTRACTOR NAME oil E ui meet Service <br />PHONE 209-754-1808 <br />N <br />T <br />CONTRACTOR ADDRESS OX CA LIC # 323417 CLASS A-Haz <br />R <br />A <br />INSURER On file <br />WORK.COMP.# <br />On file <br />C <br />FIRE DISTRICT San Joaquin County <br />PERMIT # <br />0 <br />LABORATORY NAME <br />PHONE # <br />R <br />SAMPLING FIRM PHONE # <br />1111111111TANK 1lD1#11111111111 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- i <br />T <br />39- 5000 Leaded GaGol i nP JJnknown <br />A <br />39- 5 0 0 0 <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P 111111 11111 1 Ifl f !II 1! !!II 1 11111111 1111111 1 I I I III 1 1 1 1! I 1111!!1 1111 Il11 111�iI�Til <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />_ <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />11111111111111111111111111111111111 mmin mminnuffffffnTmimmi <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I 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 THEPERF OF THE F R WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />;WORK <br />COMPENSATION LAWS OF CAL RNI ." <br />APPLICANT'S SIGNATURE: TITLE Agent DATE 9/27/99 <br />'016e1 A, Tall is <br />EH 23 046 (Revised 4/26/94) Page 3 <br />