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PAYMENT <br /> qq^.'MH-l.l.^"pDSp"9pp_D91.0 U 1.1999""X,1:ggppqqp^as v:aIkt RECEIVED <br /> L, q APPLICATION FOR PERMIT p SAN JOAQUIN LOCAL HEALTH DISTRICT q <br /> i p UNDERGROUND TANK p 1601 E HAZELION AVE., STOCKTON CA p JAN 10 19 3 9 <br /> p CLOSURE OR ALANOONMENT q Telephone (209) 4GS-3430 p <br /> ggqppppppqpqqqqppqqppqpqqqqppqppqpggpqqpqppppqqplipppnppqupppqpppqp ENVIRONMENTAL HEALTH <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCHR19'dITA1`(EFACMITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> '41 <br /> X- REMOVAL ----- TEMPORARY CLOSURE ---- ABANDONMENT IN PLACEIfnM <br /> EPA SITE 1 CAD981466402 PROJECT CONTACT 1 TELEPHONE 1 (REG <br /> G CRAI 5 U <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 OWNER/OPERATOR ALFRED "NICK" PEVA PHONE 1 (209) 835-7254 <br /> Y <br /> C CONTRACTOR NAME PETRO-CHECK, INC. PHONE 1 (916) 927-8155 <br /> O <br /> N CONTRACTOR ADDRESS 271 OPPORTUNITY ST. SUITE C CA LIC 1 533721 CLASS A <br /> T SACRAMENTO, CA 9583 <br /> R INSURER ANGIE CORNWELL INSURANCE AGENCY, INC. WORK.COMP.1 1056580-88 <br /> A - -- -- <br /> C FIRE DISTRICT `ACY RURAL PERMIT UINSPTR <br /> 0 LABORATORY NAME AMERICAN ENVIRONMENTAL PHONE 1 (916) 364-8872 <br /> R <br /> SAMPLING FIRM• AMERICAN ENVIRONMENTAL SAMPLINGMETHODEACH END OF TANK ANALYZED FOR: <br /> TPH; BXT & E; T.E.L; & E.D.B. <br /> TANK 10 1 TAI(K SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSLY <br /> T 10,000 EMPTY REGULAR <br /> A 39- — <br /> N 39- <br /> ---------------------- 10,000 <br /> K 09 ---------------------------------- 10,000 Eh1PTYSUPER UNLEADED <br /> 39 ---------------------- <br /> ----------------------------- <br /> LIST <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> rERS <br /> P APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L (SEE ATTACHMENT WITH CONDITIONS) <br /> ANNAME PATE <br /> -------------------------------------------------------------- ------------------------------ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOADUIN 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, l 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 /> 10 WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED . - DATE---,/—S.g9------------ <br /> - <br /> OFFICE USE R°LY - -- -- <br /> --------------------------- <br /> ifiiiiifftfftffiftftftfftfftfttffffIts ttf'"'!tfltftSftfftftliffffttttiffttftt{itttfftttf�"'Sttifffftffftttfffttfftfftlftf <br /> SUEEPS 1 1 <br /> COMP 1 LOC CODE IDIST CODEI ,IIT DUE i AMOUNT RCVD i Cr.l/CASH ' RCVD „ i DATE P.CVD I PERMIT 1 <br />