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rr I <br /> ism"xp"!.!:A�:i:": 9!=::1A:gHimSq.".R'".7:b'.g"pr in 09 I <br /> a APPLIC,,'I FOR PERMIT x SAN JOAQUIN LOCAL HEALTH. TR p <br /> p UNDERGROUND TANKp 1L01 E HAZELTON AVE., STOCKTON CA p D <br /> x' CLOSURE OR ABANDONMENT n Telephone (2091 4L5 3a2U (�V <br /> AMMADfln!fAifNx"7eNlRptl"�7,tp�efiggl7p}FMSnCkfIF]:;NGgfCMfiNMYplfpp3ln:Fgli:tNlfq QQ qqp�� � <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANC&-STORAEE'fACIC Y <br /> THIS PERMIT EXPIRES 30 DAYS FROM THE APPROVAL DATE. DO NOT WRITE 1N ANY SHADED AREAS. INDICATE PTIT TYPE BELOW: H <br /> XX REMOVAL TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE PLRMI I SERVIGU <br /> tf <br /> EPA SITE I CAC000194188 f PROJECT CONTACT 1 TELEPHONE 14. Gilligan 1 <br /> 0 -944-5714 <br /> F FACILITY NAME Mid Cal Tractor PHONE 1 209-944-5714 <br /> A <br /> C ADDRESS 1120 West Charter Way, Stockton, CA 95206 <br /> 1 <br /> L CROSS STREET Argonaut Street <br /> I <br /> r OWNER/OPERATOR Mid 1 Tractor PHONE I 209-944-5714 <br /> Y <br /> C CONTRACTOR NAME1 petro-Check, Inc. ')ti '(A )C(obs PHONE I 916-927-1788 <br /> 0 <br /> N CONTRACTOR ADDRESS 2076 Acoma Street CA LIC 1 533721 CLASS A <br /> T <br /> R INSURER FARMER'S INSURANCE GROUP WORK.COMP.1 1056580 <br /> A _ <br /> C FIRE DISTRICT City f Stockton PERMIT I/INmi Smi PTpi R See Atiii tachment 1. <br /> T _ <br /> 0 LABORATORY NAM . lifornia Water Labs PHONE 1 <br /> R 209-527-4050 <br /> SAMPLING FIRM* Kleinfelder & Associates SAMPLING METHOD Each end analyzed for: <br /> TPH; BTX & E; and EDB and TEL. <br /> T TANK 1D I TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSLY <br /> A 33_ 1�tL7-_Qat_-- -- 10,000 170 gals unleaded"' Unleaded <br /> N 39- 11000 40 gals—dies Diesel <br /> K 39 <br /> 39----------------------------- <br /> (This fuel will be recycled after <br /> 39----------------------------- having en pumpe ou . <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> L APPROVED APPROVED WITH CONDITIONS ___ DISAPPROVED <br /> L <br /> - (S E ATTACHMENT WITH CONDITIONS) <br /> A LAN REVIEWERS NAME ____ ---------------------------- DATE____ <br /> N �� _ � - - - --- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CDUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL F INSPEC�TIIONSASATLEAST 48 HOURS IN ADVANCE q <br /> SIGNED __�� f� 7 f� �! <br /> OFFICE E OILY � —�=---------------------------------DATE--- ---�=�------- - <br /> ftffttiftfffffffffffffffffffffffffffffffftffiffffffffffffffffiffifffffffffftffiftffffffffffffftfiffffffffffffffffffffffff <br /> SWEEPS I ' COMP 1 'LOC CODE 'OIST CODE' AMOUNT DUE ' AMOUNT RCVD CY CASH RCVD BY DATE RCVD ' PERMIT 1 <br /> /vY7 �iDrAU O/ 3�3 A6-O / dp'���a(o� 7 /e 8/y' kY <br />