Laserfiche WebLink
a APPLICATI01 PERMIT p SAN JOAQUIN LOCAL HEALTH DISI n v <br /> A UNDERGROOro TANK p IG01 E HAEELTON AVE., STOCKTOH'�A <br /> y, CLOSURE OR ABANDONMENT x Telephone (209) 4GS-3420 tl <br /> ApMCp1fMMGM�F"".t'If.&f1F:it1C^CFAeRp7ff#F.C.lte!:MFAf:%GISSfpiSpfiNF471FUCfiattFFNFtl 2Z 2 9 <br /> aim <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY 6 <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: 6°3 <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE 1 , PROJECT CONTACT 1 TELEPHONE 1 ?,REG CRAIG <br /> CAD981ew0. 916) -723-`a25 <br /> F FACILITY NAME7_t 1 PHONE 1 (409) 835-7254 <br /> A <br /> C ADDRESS 45F WEST GRANT LINE ROAD, TRACY, CA 95376 <br /> 1 <br /> L CROSS STREET BUT"MANN AVENUE <br /> I <br /> T OWNER/OPERATOR ALFRED "NICK» pENA PHONE 1 (209) 834-7254 <br /> Y <br /> C CONTRACTOR NAME PETRO-MCK, INC. PHONE tl (916) 927-8153 <br /> 0 <br /> N CONTRACTOR ADDRESS 2S7A QP_�ORTUN 95B'J� Sul TE C CA LIC 1 533721 CLASS A <br /> T wAnn�CxxltVy �8 <br /> R INSURER AN3TE CORNWELL TNSURANCE AGENCY, INC. WORK.COMPA 1O585OD-88 <br /> A — - - - <br /> C FIRE DISTRICT "`RACY RURAL, PERMIT 1/INSPTk <br /> T -- ---- ---- <br /> 0 LABORATORY NAME AMERICAN ENVTRONMENTAT PHONE 1 (916) 364-8872 <br /> R EACH END OF TANK ANALYZED FOR: <br /> SAMPLING FIRM* AMERICAN ENVIRONMENTAL SAMPLING METHODEACH <br /> HXT & EX T.E.Li & E.D.H. <br /> TANK ID 1 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STOPED PREVIOUSL <br /> T 10,000 EMPTY REGULAR <br /> A 39- 1!JQC--J -at <br /> Y. 39 ------ 10,0w 10,000 EMPTY UNLEADED <br /> N 39-____j_ygq=Q--------- 10,000 EMPTY SUPER UNLEADED <br /> -----1���---�-ice-------' - <br /> ---------------------------- <br /> 39 <br /> --------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> P PROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> L (SEE ATJACHNEMT WITH CONDITIONS) <br /> A PLAN REVIEWERS NAME ,, 1� ,9y/-- ______________ DATE Y--. <br /> ( �-N - - -- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN 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: 'I 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 THE 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 INSPrECnT(�IONS AT LEAST 46 HOURS IN ADVANCE p <br /> DATE -5- �-� - <br /> OFFICE USE ONLY <br /> ffffffff tititffiftfff iffffffffi tiff Sff ftitifffffiffftfff tffifffffffffif fftSiif ifSfSSffffiSSfffSfffifffiffSffSSffftffffS <br /> LVICEPC 1 ' COMP t LOC CODE 'DIST CODE' AMOUNT DUE ' AMOUNT RCVD ' C!. CASH RCV BY DA E RCVD PERMIT 1 <br /> i -T �� <br />