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RECEIVED <br /> p APPLICATF 'OR PERMIT # SAN JOAQUIN LOCAL HEALTH OI ^ ' ,T p <br /> p UNDERNPAD TANK tt 1641 E HAZELTON AVE., STOCKWJ, CA p A� p 1999 <br /> CLOSURE OR ABANDONMENT Telephone (20 ) 463-3320 <br /> aaaauaaaaaaaaKaa.aaaaau�snaasaaaaaaaa�sa.,aaa-aaaaa.sa:faaaaawAanaaaaau ENVIRONMENTAL HEALTH <br /> APPLICATION FOR P£RNANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANC?FWMW1A011E Y <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _ REMOVAL TEMPORARY CLOSURE ___- ABANDONMENT IN PLACE <br /> EPA SITE 1 M981466402 PROJECT CONTACT & TELEPHONE 1 G(9 G CRAIG5425 <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 /> I <br /> L CROSS STREET BU'THMANN AVENUE <br /> I <br /> T OWNERIOPERATOR ALFRED "NICK" PELTA PHONE 1 (209) 835-7254 <br /> I Y <br /> C CONTRACTOR NAME PETRO—CHECK, INC. PHONE 1 (916) 927-8155 <br /> I O <br /> N CONTRACTOR ADDRESS 22771 OPPORTUNITYCRAMENTO, CA STSUITE C CA LIC 1 533721 CLASS A <br /> T <br /> R INSURER ANGIE CORNWELL INSURANCE AGENCY, INC. WORK.COMP.1 1056580-88 <br /> A <br /> C FIRE DISTRICT TRAM Mm F_1(16 �>EPT PERMIT 11INSPTR <br /> T r <br /> 0 LABORATORY NAME AMERICAN ENVIRONMEN'T'AL PHONE 1 (916) 364-8872 <br /> R EACH END OF TANK ANALYZED FOR: <br /> SAMPLING FIRM• AMERICAN ENVIRONMENTAL SAMPLING METHOD TPH; BXT & E; T.E.L; & E.D.B. <br /> TANK 10 1 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREVIOUSLY <br /> T <br /> A 39- /'r7lO�1 — G/ 10,000 EMPTY REGULAR <br /> N 39- 0 EMPTY <br /> ---r -- .Z----- 10 00 <br /> 10,000 EMPTY i <br /> ' 33--------------------------- <br /> 39---------------------------- <br /> LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARAIE FORM <br /> j P ____ APPROVED APPROVED WITH CONDITIONS __ DISAPPROVED <br /> L (SEE ATTACHMENT WITH CONDITIONS) <br /> A LAN REVIEWERS NAMEl/17 ---- �?✓� �-____-- DATE___--�__f ------- <br /> ----------- .................... ....] <br /> APPLICAN <br /> ----_---------- <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: 'I CERTIFY THAT <br /> IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MAHNER 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 SUBJEC <br /> TO WORKER'S CONPENSATION LAWS OF CALIFORNIA. <br /> CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br /> SIGNED _a�- -------------- -- ---------------------------------------DATE__1-S_=g�___-------- <br /> OFFICE USE OILY - <br /> ififftittitftffitfSSfiftiffffffififif itifffifffffffifffififfitttif fiffiiifiifffftftfttftfitfffiffif4�fffiffffffiffif <br /> SWEEPS 1 ' COMP 1 'LOC CODE 'OIST COD AMOUNT DUE ' AMOUNT RCVD Cy <br /> CASH RCVD BY DATE RCVD ' PERMIT <br /> �w x.. 70 .2- <br />