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PAYMENT <br /> RECEIVED <br /> .h..N.::��w�9:.'w- ~ t:.�.nn:.'�ww..�:.t::..wwnhH KfSK rtlt 1(htifi SSwiww�i n:.'n S::.�wn�n:.'n{`••.- -•�^�^ <br /> w..-wwwnwnnw <br /> p APPLIC► .'OR PEP.MIT q SAN JDAGUIN LOCAL.HEALTH� •T a <br /> q UNDERG,OUHD TANr q IGOI E HAIELTOH AVE., STOCI;i:lll CA pJAN 10 <br /> 1ng 1 <br /> CLOSURE OR ABANDONMENT a Telephone (209) 4G9 2420 q <br /> aaaaassaapauaa«assaaanaaaKpanaaaaaaapssaa sifgaaaraaa:sassss+sa;saaaassasEs;aass ENVIRONMENTAL HEALTH <br /> APPLICATION FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCHWWVWIEM <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X_ REMOVAL TEMPORARY CLOSURE __-_ ABANDONMENT IN PLACE Cq� <br /> PROJECT CONTACT >r TELEPHONE 1 REG CRAIG <br /> SITE 1 CAD981466402 G{916) 723-5425 <br /> FAE LITY NAME 7-11 PHONE 11 (209) 835-7254 <br /> C ADDRESS455 WEST GRANT LINE ROAD, TRACY, CA 95376 <br /> 1 <br /> L CROSS STREET BULHMANN AVENUE <br /> 1 <br /> T OWNER/OPERATOR ALFRED "NICK" PENN PHONE 1 (20g) 835-7254 <br /> Y i <br /> C CONTRACTOR NAME PETRO-CFIEHONE 1 CK. INCINC• (916) 927-8155 <br /> 0 CLASS A <br /> N CONTRACTOR ADDRESS 271 OPPORTUNITY <br /> CA 95$3 SUITE C CA LIC 1 533721 <br /> T <br /> F. INSURER ANGIE CORNWELL INSURANCE AGENCY, INC. <br /> ' N�.COM <br /> 1056580-88 <br /> A C FIRE DISTRICT TRACY r 'RE -i>eeT <br /> - <br /> PERMIT 11INSPTR <br /> 0 LABORATORY NAME AMERICAN ENVIRONMENTAL PHONE 1 (916} 364-8872 <br /> R EACH END OF TANK ANALYZED FOR <br /> SAMPLING FIRM' AMERICAN ENVIRONMENTAL SAMPLING METHOD TM; M & E; T.E.L; & E.D.B. <br /> TANK 10 1 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STOPED PREVIOUSLY <br /> A - / b -_C?/ 10,000 EMPTY REGULAR <br /> N 39- � 4 _--�Z"--___ 10,009 <br /> __4_.�-___-- 10,000 EMPTY . <br /> 39---------------------------- <br /> 39---------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> =ti <br /> P APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L (SEE ATT- HMEH WITH CONDITIONSI <br /> DATE ZZf T l ----A PLAN REVIEWERS NAME �'�1��---- -_��-- ---------------------- ----_-_- --- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES 490 REGULATIONS <br /> OF THE SAN JOADUIN LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br /> 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO DECOM <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING. 'I CERTIFY THAT IN INE 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 FOR INSPECTIONS AT LEAST - 48 HOURS IN ADVANCE <br /> --- ---- ----------- _DATE---1—S—g ------------ <br /> SlGNfB--- -- - •- - �--------------- --------------- -------- <br /> OFFICE OSE ONLY <br /> tttittitsttttt3ii##i3t3###SSSS####Sit##3#3ti3#s#####3f3fittt#t33ii#ttf3t#3#tit;fii##t#f#t3ii##33t##f#3#i3t3##33ti3i3333### <br /> SWEEPS I ' COMP 1 'LOC CODE 'DIST CODE' AMOUNT DUE ' AMOUNT RCVD CY CASH RCVD BY DATE RCVD ! PERMIT I <br />