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• �' ^ • nnnnaaaitetrtur+ia PERMIT nKKwN�i»?�:.`.�#�#:::;-�..:,��#�:�:�»��':!n'w <br /> SAH JOAQUIN LOCAL HEALTH <br /> UNOE nu TANK # 101 E 1{AIELTON AVE., STOr m1i a p <br /> CLOSURE OR AL K Telephone (20`ii 465-34?U q <br /> ` #pf:fF#!f!f!f##!f#A#rfFk�##IfKR###Sf:F####3f#!f##I��KR##S:#1�1FSftf:ffi�#fSIiAEi#u#A:i}:{i:iNf�# � i t' <br /> APPLICATION FOR PERMANENTITENPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE DELON: <br /> REMOVAL TEMPORARY CLOSURE ____ ABANDONMENT IN PLACE <br /> EPA SITE # CAD9814fi5402 PROJECT CONTACT x TELEPHONE # RE6)C�RAAIa5AZ5 <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 /> L CROSS STREET Bu7lRvm AVENUE <br /> I <br /> T OWNER/OPERATOR Al PED wNICK" PERA PHONE 1 (209) 835-72.54 <br /> Y <br /> C CONTRACTOR NAME PETRO-4::�, INC. PHONE 1 (916) 927-8155 <br /> O <br /> N CONTRACTOR ADDRESS 271 OPPORTUNTTY � SCUTE C CA LIC 1 533721 CLASS A <br /> T SACRAMEMIn CA 906 <br /> R INSURER ANGIE CORN6dE L INSURANCE AGENCY, INC. 9ORK.COMP.1 10565801-88 <br /> A - -- <br /> C FIRE DISTRICT TRACY RURAL PERMIT IIINSPTR <br /> T ---- <br /> O LABORATORY NAME AMERICAN MTRONMErIAL PHOI4E 1 (916) 364-8872 <br /> R EACH END OF TANK ANALYZED FOR: <br /> SAMPLING FIRM• AMERICAN ENVIRONf�EMI'AL SAMPLING METHOD TPN; SXT & Ep T.E.LT & E.D.B. <br /> TANK ID 1 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS.SIOP.ED PREVIOUSL <br /> A 35..... } _O -------- <br /> _. 10,000 REGULAR <br /> :Q Z=------ 10,QOD EMPTY UNLEADED <br /> Y, 33-_----��f Q _ O IQ's`- �"E'`TY SUPER UNLEADED <br /> 39- <br /> 39----------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> K <br /> P _ e4PPOVED APPROVED WITH CONDITIONS _` DISAPPROVED <br /> L (SEE A;IACHMENT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME ---------- --------------------------------------DATE__- Y -____-- <br /> -- <br /> N <br /> F"ammi <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: '1 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 IHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br /> TO WORKER'S COMPENSATION LAMS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE q <br /> t <br /> SIGNED-- -_ ---- ----------------------------------------DATE---1=S: .].._--._----- <br /> QfFJCf USE DALY <br /> ssssssssszsssssssssssssssssszsssssszt:stststssssssssssssssttsttsstssssst sstttzsssssssssssstsstsssszsssssstssstststsssssss <br /> SUEEPE I ' COMP I LOC CODE 'DIST CODE' AMOUNT DUE ' AMOUNT RCVD CI. CASH RCV BY DA E RCVD PERMIT 1 <br /> Ity2 <br />