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3 of 10 <br />Environmental Health Department <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 # PROJECT CONTACT PHONE# <br />FACILITY NAME PHONE # <br />ADDRESS <br />CROSS STREET <br />OWNER OPERATOR PHONE # <br />CONTRACTOR INFORMATION <br />CONTRACTOR NAME PHONE # <br />CONTRACTOR ADDRESS CA LIC # CLASS <br />INSURER WORKER COMP# <br />FIRE DISTRICT PERMIT # <br />LABORATORY NAME COUNTY PHONE # <br />SAMPLING FIRM PHONE # <br />TANK INFORMATION <br />TANK ID # TANK SIZE TANK CONTENTS (PRESENT AND PAST) DATE INSTALLED <br />39- <br />39- <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 WORKER’S COMPENSATION LAWS OF CALIFORNIA.” <br />APPLICANT’S SIGNATURE _____________________________________ TITLE ________________________________DATE_____________ <br />APPROVED APPROVED WITH CONDITION(S)DISAPPROVED <br />(SEE CONDITIONS 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 />_____________________________________________________________________________ <br />_____________________________________________________________________________ <br />Brett Baatrup <br />Former Valero Gas Station <br />1210 E. Hammer Lane, Stockton, CA 95210 <br />Kathleen Dr <br />Innovative Construction Solutions <br />575 Anton Blvd Suite 850, Costa Mesa, CA 92626 764815 A-HAZ-C21 <br />(714) 893-6366 <br />Marsh & McLennan Insurance Agency LLC <br />12,000 gallons Regular gasoline <br />10,000 gallons Diesel <br />10,000 gallons <br />Project Manager <br />(925) 864-8292 <br />WC551375110 <br />First Evergreen Oil Corporation <br />0002311250506247 <br />0002311250506248 <br />0002311250506249 <br />5/28/1996 <br />5/28/1996 <br />5/28/1996Premium gasoline <br />ENGEO <br />Santa Clara <br />CAL000405163 <br />209-482-2680 <br />408-263-5258 <br />925-570-5855 <br />Torrent Laboratory, Milpitas, CA <br />N/A <br />Stockton Fire Department <br />7/02/2025