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l <br />I <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SE: <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK C <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AR S. INDICA <br />< REMOVAL _ TEMPORARY CLOSURE CU <br />i <br />:CES <br />S PERbIIT <br />DOUS SUBSTANCE STORAGE TANK <br />MIT TYPE BELOW: <br />IN PLACE <br />CONDITION(S): I Cz kt,* J 5�rJQ//{J `8-' e(>•c ,%z �n ^ <br />L ` Su- u � 1 51 '71 � I 0 <br />.� . 64 6-r� u g A -013 pro" �D ccrm-wjLl j <br />kwk-. <br />E4 Z3 046 (Revised 9/11/96) `/ <br />EPA SITE <br />PROJECT CONTACT & TTEELEPH NE # fi�aoj rjary"Q'I'r (q IG) (oat -7711 <br />F <br />.,,,1 <br />FACILITY NAME GJO�I•dtJ 7 -eleven Zbre41411 I <br />PHONE # <br />A <br />ADDRESS 2725 GOv� Glum blvd- OR <br />I <br />P <br />L <br />I <br />CROSS STREET Ryde <br />Y <br />OWNER/OPERATOR T�1C },I_land �QI'�ra,�l�n PHONE # <br />V1`) (I*)&15 7711 <br />C <br />CONTRACTOR NAME ManeS5 COY raF�on I PHONE # `�j(oZ) �r�_q,c c,, <br />0 <br />N <br />CONTRACTOR ADDRESS 1101 E. rinr 3 !jtrca', F7 <br />CA LIC # 55- i 33 <br />CLASS <br />T <br />G12 G21 G2'F G�7 <br />R <br />INSURER Nat. Union Fjra Ins. Co. I WORK.COMP.X WC8I-7djol <br />A <br />FIRE DLS. I PERMIT # <br />LABORATORY NAME + L96onai'orieS Y yolo PHONE # (`11G)757 -09Z0 <br />AMP Fluor - I�'Jnial� STI PHONE # (97-5) $70-3990 <br />11 11111111111111111 <br />39 J .SANK ID # TAN Z CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />/5 -v/ <br />T <br />39-U <br />ar Uni'd l 7 <br />A <br />39- o- - <br />IOGt7 hlid-Cx16a Uri 1996 <br />N <br />39- <br />_(h<w+iywyn a t972 <br />K <br />39- <br />39- <br />39- <br />P 1!11111 111 Illi! I I I I I I I 111 I I II !1 I Iillllllllllll <br />L_ APPROVE APPROVED WITH CONDITIONS) DISAPPROVED <br />A BELOW AND/OR ON A ACHMENT) <br />L—E-CONDITIONS <br />N <br />PLAN REVIEWER'S NAME �'�� DATE '7- 3-c4 <br />11111111 <br />1111111111111111 111111111111111111111111111111111111111111111111111111111111 <br />APPLICANT MUST PERFORM ALL WORK 1 ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE of 2HL n TITLE AL)eAI 1<X �bAl2M DATE 'q- Imo! -la <br />1 <br />CONDITION(S): I Cz kt,* J 5�rJQ//{J `8-' e(>•c ,%z �n ^ <br />L ` Su- u � 1 51 '71 � I 0 <br />.� . 64 6-r� u g A -013 pro" �D ccrm-wjLl j <br />kwk-. <br />E4 Z3 046 (Revised 9/11/96) `/ <br />