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r� a At'YIIGAllUlawo call p yAM JUAMA LUI.AL nLALIn <br /> a <br /> UNDERGROUND C 1501 E HAIELiON AVE., S10CKIDH CA 0A <br /> CLOSURE OR AD*wcNMENT g Telephone (209) 45S-3320 <br /> aaagaaa�aaaaaaraaaa � �:aaaanaa� as as«ttAaaaaasns s�ansttaaasaaa u a ; =j <br /> APPLICATION FOR PEP.MAHENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY.. <br /> THIS PERMIT EIPIP.ES 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 Ir PROJECT CONTACT 1, TELEPHONE I Stella Ruiz <br /> J 209 835-7554 <br /> F FACILITY NAME RUIZ CORNER GROCERY PHONE I (209) 835-7554 <br /> A <br /> C ADDRESS 4.491 West Durham Ferry Road, Tracy, CA 95376 <br /> I <br /> L CROSS STREET Bird Street <br /> I <br /> T OWNEMPERATOR Stella Ruiz PHONE 1 (209) 835-7554 <br /> Y Ruiz Corner Grocery _ <br /> C CONTRACTOR NAME Petro-Check, Inc. PHONE 1 (916) 927-8155 <br /> 0 <br /> N CONTRACTOR ADDRESS 271 Opportunity Street, Suite C CA LIC 1 533722CLASS A <br /> T — Sacramento. CA 95838 <br /> R INSURER Angie Cornwell Insurance Agency Inc. WORK.COMP.I 1056580-88 <br /> A - <br /> C FIRE DISTRICT TRACY RURAL PERMIT IIINSPTR <br /> T — <br /> 0 LABORATORY NAME AMERICAN ENVIRONMENTAL I� CORP PHONE 1 916-364-8872 <br /> R <br /> SAMPLING FIP,M-AMERICAN ENVImz=AL m3mr SAMPLING METHOD Each and of tank analyzed for: <br /> T.P.H. and BTX & E. <br /> TANK ID I TANK SIIE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSLY <br /> T-A39 �$�f -Q/ 1,000 Empty <br /> 1 000 t " E1aso s <br /> K 39-tAPLAX <br /> -------------------------- <br /> --------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br /> pPPROVEO APPROVED WITH CONDITIONS DISAPPROVED <br /> (SEE ATTACHMENT VITH CONDITIONS) _ <br /> REVIEWERS NAME ------S,. /�r�1 _ i¢((l -__..-___-.____. -__---SATE------�-�._.... <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> OF THE SAN JOAOUIN LOCAL HEALTH DISTRICT. 09HER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:_'1 CERTIFY THAT <br /> 1N THE PERFORMANCE•OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUc1%XNANd1COM <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATIONGEO 11EYMP <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL Fel PEVON�?jJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. hh <br /> CAL R INSP CTIONS T LEAST 48 HOURS IN ADV Nom. <br /> SIGHED - ------------------------------------DATE„O_Z: �P...:_ s. . <br /> OFFICE OSE OILY <br /> ssss$ssssssssssssssssssssssssssssissssssssssssssssssisissssssssssisssssssssssisssssssssssssssssssssssssssssssssssaississs ,41 <br /> SWEEPS I..' OMP-1,� LOC CODE -'DIST.CODE' AMOUNT DUE ' AMOUNT.P.CVO '; CKI/CASH RCVO BY DATE P.CVD.- - PERMIT 1 I <br /> U_3 ., . .�, ., . <br /> - --- - --•---- �._.... .. ..�...�.. ..... �..-.a,.v.,u a ivy aci^ci iiia 1-OVV-JwO-HOJy __ rw"""'_""'�, . .�c..�I <br />