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SANO A Q 1 Environmental Health Department <br /> — COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE IT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS <br /> SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE , DO NOT WRITE IN ANY SHADED AREAS, <br /> INDICATE PERMIT TYPE : <br /> ❑ REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # CAC003136477 PROJECT CONTACT Sarah Jablonsky " Construction Manager PHONE# 916-373- 1165 <br /> FACILITY NAME 7-Eleven #41342 . PHONE # NIA <br /> ADDRESS 1233 Dr. MLK Jr, Blvd, , Stockton , CA 95205 <br /> CROSS STREET S . Airport Way <br /> OWNER OPERATOR 7- Eleven , Inc. PHONE # 916-742-0232 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Walton Engineering , Inc. IPHONE # <br /> CONTRACTOR ADDRESS PO Box 1025 , West Sacramento , CA 95691 1 CA LIC # 617238 CLASS A , B; Haz <br /> INSURER State Compensation Insurance FundWORKER COMP# 9113339 <br /> FIRE DISTRICT Stockton Fire Department PERMIT # BP20-05193 <br /> LABORATORY NAME Sunstar Laboratories , Inc. COUNTY Orange County PHONE # 949-297"5020 � <br /> SAMPLING FIRM Terracon Consultants PHONE # 916-928 -4690 <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39- 1 Aprox. 500 gal . None I Unknown Unknown <br /> 39- <br /> 39- ' <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS, FEDERAL LAWS, AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE <br /> FOLLOWING: °i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: °I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA," <br /> APPLICANT'S SIGNATURE /$ TITLE COnSCUC$IOn Manager DATE air <br /> ❑ APPROVED as APPROVED WITH CONDITION (S) ❑ DISAPPROVED <br /> (SEE CpNbIMNS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME 24- <br /> DATE <br /> ANY DEVIATIONS FROM THIS AOKICATIC?I MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS : <br /> i <br /> 3of10 <br />