Laserfiche WebLink
p A?rL1CAIIUh%; AA11 p JAM JUAUUTA LUI.AL nLA4.1n uij.,,;l� <br /> UNDERGROUND TANK x 1601 E HAIELTON AVE., STOCKTON CA <br /> CLOSURE OR ACANDONMENT Telephone (203) 4GS-3420 <br /> h>;'>lSfpSfflEIC>;:�"SSlf1;pA.'1!:k'9SCi'h.�p91�.111�3L„tlf>A�9>iffS4C�plfSfflflpAllApSLpplf3l0 � ., �':� <br /> • - —J qNn <br /> z'- <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAIARDOUS SUBSTANCES STORAGE FACILITY_ <br /> THIS PERMIT EIPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _ REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE # PROJECT CONTACT Z TELEPHONE 1 Stella Ruiz <br /> 209 835-7554 <br /> F FACILITY NAME RUIZ CORNER GROCERY PRONE # (209) 835-7554 <br /> A <br /> C ADDRESS 4491 West Durham Ferry Road, Tracy, CA 95376 <br /> 1 <br /> L CROSS STREET Bird Street <br /> I <br /> T OWNER/OPERATOR Stella Ruiz PHONE 1 (209) 835-7554 <br /> Y Ruiz Corner Grocery <br /> C CONIP,ACTOR NAME Petro-Check, Inc. PHONE 1 (916) 927-8155 ; <br /> ; 0 <br /> N CONTRACTOR ADDRESS 271 Opportunity Street, Suite C CA LIC 1 533721 CLASS A <br /> � ISarri5mentn, CA 95838Y <br /> R INSURER Angie Cornwell Insurance Agency Inc. WORK.COMPA 1056580-88 <br /> A <br /> C FIRE DISTRICT TRACY RURAL PERMIT IJINSPTR <br /> T <br /> 0 LABORATORY NAME AMERICAN ENVIRONMENTAL MMT CORP PHONE 1 916-364-8872 <br /> � R Each end of tank analyzed for: <br /> SAMPLING F1P.M•AMERICAN ENVIRONMENTAL M3M SAMPLING METHOD T.P.H. and BTX S. E. <br /> TANK ID # TANK SITE CHEMICALS STORED CURRENTLY CHEMICALS STOREDPREVIOUSLY <br /> T _ 11000 Empty Gaol i'line <br /> A b- -----—Q/------- 1 000 t u baso i <br /> H 35- <br /> K39'-------------------------- '4 <br /> 39---»---------------------- <br /> 39-tAPLAN <br /> -------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> APPROVED APPROVED WIIH CONDITIONS ___ DISAPPROVED <br /> (SEE ATTACHMENT WITH CONDITIONS) _ <br /> REVIEWERS NAME _--------5.. /2 _C Lel --_-_____-_------------ OATE------ -r - ------ <br /> APPLICANT MUST PERFORM ALL YORK IN ACCORDANCE WITH SAN JOADUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWL064-6 1 CERTIFY THAT <br /> IN THE PERFORMANCE-OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCP11�1Y-MANBTCOM <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONIRACTOR'S (TIRING OR SUBCONTRACTING SIGNATAr RAIN WIVES <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL V� PE O' JEC <br /> TO WORKER'S COMPENSATION LAYS OF CALIFORNIA. <br /> CAL R INSP CTIONS AT LEAST 48 HOURS IN ADV PJTALW <br /> WI W <br /> �* <br /> DATE <br /> , <br /> ------------------------------------------- - - --- <br /> OFFICE OSE OMIT <br /> ssssssssscsscssssssssssl`ssstssssstsssss�:sssssssssss:ssssssscsssssssssssssssscsssssssssssssssssssssssssssssssssssssssssss . <br /> SWEEPS 1 ' COMP f - LOC CODE.'DIST L'OaEJ AMOUNT DUE ' AMOUNT_PCVDj,. CCI/CISH RCVD BY ' DATE !CVD �.PWIT 1 <br /> J ivh rv) <br />