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PAYMENT <br /> sssssss:ass ss^:assns^sssssssssssssssssssss::ss:aasss::s' '�'s; <br /> p APPLICATI%wJR PERMIT p SAN JOAQUIN LOCAL HEALTH DI, .T p RECEIVED <br /> p UNDERGROUND TANK p 1601 E HAZELTON AVE., STOCKTON CA p JAN 10 1g g g <br /> p CLOSURE OR ABANDONMENT s Telephone (209) 465-3420 1 <br /> pN111pMppplMnpSpppplip.�7pptlpepMANMpptlp7pppl:pnppp:SpANpp77ppppfiL�pGYNp ENVIRONMENTAL HEALTH <br /> APPLICATION FOR PERMANENUTEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCUR4VdITA FACIEM <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 ABANDONMENT IN PLACE <br /> EPA SITE 1 CAD981466402 PROJECT CONTACT 4 TELEPHONE 1 (9 6)C723G5425 <br /> F FACILITY NAME 7-11 PHONE 1 (209) 835-7254 <br /> A <br /> C ADDRESS 455 WEST GRANT LINE ROAD, TRACY, CA 95376 <br /> 1 — <br /> L CROSS STREET BUTHMANN AVENUE <br /> I <br /> T OWNERIOPERATOR ALFRED "NICK" PERA PHONE 1 (209) 835-7254 <br /> Y <br /> C CONTRACTOR NAME PETRO—COCK, INC. PHONE 1 (916) 927-8155 <br /> O <br /> N CONTRACTOR ADDRESS 271 OPPORTUNITY ST. , SUITE C CA LIC 1 533721 CLASS A <br /> I SACRAMENTO, CA 95838 <br /> R INSURER ANGIE CORNWELL INSURANCE AGENCY, INC. WORK.COMPA 1056580-88 <br /> A _ — --- <br /> C FIRE DISTRICT TRACY F-1 R'C 10,6pT PERMIT UINSPTR <br /> O LABORATORY NAME AMERICAN ENVIRONMENTAL PHONE 1 (916) 364-8872 <br /> R EACH END OF TANK ANALYZED FOR: <br /> SAMPLING FIRM* AMERICAN ENVIRONMENTAL SAMPLING METHOD TPH; BXT & E; T.E.L; & E.D.B. <br /> TAIIK ID 1 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STOPED PREVIOUSLY <br /> T 10,000 EMPTY REGULAR <br /> A 39 r/ -_c�/ _ <br /> 1 ��- - EMPTY TJNTP.AT)FD <br /> 42Z- -- 10 000 <br /> - _ - - -- 10,000 EMPTY <br /> 39 ---------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P APPROVED APPROVED WITH CONDITIONS ____ DISAPPROVED <br /> L (SEE ATTACHMEN WITH CONDITIONS) / <br /> A PLAN REVIEWERS NAME y l/% --- i�� -------------------DATE-------- _�` �`� <br /> -------- <br /> N <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY 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 1S 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, 1 SHALL EMPLOY PERSONS SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED---1�U 5!� —Y� ` --------------------------------------DATE-- J- 5-—g g----------- <br /> l <br /> OFFICE USE ONLY <br /> ffifffffSfffSfiffSSSfStfStSSSSSftSffSfiSSSiSiffftfSfftffSfftiSSStfSSSSf1SSStttifffSfSfSfftitStSSSffftitfStfftfittfftSfttft <br /> SWEEPS 1 ' COMP t 'LOC CODE '01ST CODE' AMOUNT DUE ' AMOUNT RCVDf,Y. CASH RCVD BY DATE Rf,VD PERMIT 1 <br />