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f j'M <br /> � Ir <br /> ,i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> i <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 IH ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> XX p <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # PROJECT CONTACT & TELEPHONE At <br /> Mr. Heng Chea (209) 463 4114 <br /> F FACILITY NAME Waterloo Liquor �' PHONE # (209) 463 4114 <br /> A <br /> C ADDRESS 2512_ E. Waterloo Road, Stockton, California 95205 <br /> I <br /> L CROSS STREET Filbert <br /> I <br /> T OWNER/OPERATOR Mr. Heng Chea if PHONE # (209) 463 4114 <br /> Y <br /> CO } CONTRACTOR NAME .Tames J. Hoblitzell { �;L PHONE # (209) 943 7793 <br /> N CONTRACTOR ADDRESS P.O. Box 30331, Stockton,Ca95213 CA LIC it 365234 CLASS A-Naz <br /> T <br /> R INSURER NA it WORK.COMP.# Exempt <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 LABORATORY NAME Mc Campbell Analytical j; PHONE # (510) 791 1986 <br /> R <br /> SAMPLING FIRM Upgradient Environmental PHONE # (209) 772 3620 <br /> 11111111111!l1111111111111111 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENT Y/ REYI LY DATE UST INSTALLED <br /> 39- — I 1 ,000unleaded gasoline 'a unknown 7 <br /> T 39- — --- 7 000 � � <br /> A 39- �2 nnn n ea a aso ine unknown G. ! G y <br /> N 39- � } <br /> K 39- <br /> 39- <br /> 39-- <br /> 11111ffffiff <br /> P <br /> L APPROVED APPROVED WITH CONDITION($) ,i DISAPPROVED <br /> A (XEEjAWj:HMENT WITH CONDITIONS) �f q DATE.01 C2G <br /> N PLAN REVIEWERS NAME <br /> IIIIIIIIIIIIIIIIIIII �� IIIA <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 SIGNATUREJ: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 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,'�I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA_" <br /> APPLICANT'S SIGNATURE: TITLE'.,O- WQ:yrl, _ DATE ` -Ser <br />' r P: <br /> �- <br /> / - i, <br /> -3 <br /> EH 23 0 ( s 4 age 3 <br /> f � iL <br />