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SANJOAQUIN Environmental Health Department <br /> ----- C O U N T Y — - <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS <br /> SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE , DO NOT WRITE IN ANY SHADED AREAS , <br /> INDICATE PERMIT TYPE: <br /> ❑ REMOVAL TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # CAL000104482 PROJECT CONTACT Sarah Jablonsk -Construction Mn r. PHONE# 916-373- 1165 <br /> FACILITY NAME Pacific Car Wash PHONE # 209-478-5504 <br /> ADDRESS 4405 Pacfic Ave . , Stockton , CA 95207 <br /> CROSS STREET <br /> Bianchi g(j - <br /> OWNER OPERATOR STHEM LLC PHONE # 510-268-8500 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Walton Engineering PHONE # 916-373- 1165 <br /> CONTRACTOR ADDRESS PO Box 1025 West Sacramento CA 95691 CA LIC # 617238 CLASS A , B , Haz <br /> INSURER State Fund WORKER COMP# 9113339 <br /> FIRE DISTRICT PERMIT # <br /> LABORATORY NAME COUNTY PHONE # <br /> SAMPLING FIRM Adams Services PHONE" 310-5234430 <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED <br /> 39 - 1 12K 87- 12 , 000 gal . 09/22/ 1999 <br /> 39- 2 8K 91 -8 , 000 gal . 09/29/1999 <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 AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: " I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. " CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORK3MPENSATIO OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE TITLE Michael Walton-President DATE <br /> ❑ APPROVED YAPPROVED WITH CONDITION (S) ❑ DISAPPROVED <br /> (SEE OM TIONS BELOW AND/OR ON ATTACHMENT) �1 J / <br /> PLAN REVIEWER' S NAME �� DATE / 1* ZO <br /> ANY DEVIATIONS FROM THIS APP ION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK, <br /> CONDITIONS : <br /> 3of10 <br />