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SAN J O A Q U I N Environmental Health Department <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTTEMPORARY 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 /> IZ REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # CAD981465255 I PROJECT CONTACT HOWARD JONES PHONE# 714-715-7309 <br /> FACILITY NAME : 7-Eleven Store No . 17334 IPHONE # <br /> ADDRESS : 4501 N . Pershing Ave . , Stockton , CA 95207 <br /> CROSS STREET : Rosemarie Ln <br /> OWNER OPERATOR Paula Sime PHONE # 951 -395-2710 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME : Innovative Construction Solutions ( ICS) PHONE # 925-574-2600 <br /> CONTRACTOR ADDRESS : 2525 Stanwell Drive , Suite 200 , Concord , CA 94520 CA LIC # : 764815 CLASS : A , HAZ , C21 <br /> INSURER : ACORD WORKER COMP# WC 040306 <br /> FIRE DISTRICT City of Stockton PERMIT # SFD22-535644 <br /> LABORATORY NAME : Pace Analytical COUNTY : San Joaquin I PHONE # <br /> SAMPLING FIRM : Stantec PHONE # 858-633-4222 <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS (PRESENT AND PAS DATE INSTALLED <br /> 39- 10 , 000 gal Gasoline April 1998 <br /> 39- 10 , 000 gal Gasoline April 1998 <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 AGENT'S 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'SOMPE,NNSSATIO LAWS OF CALIFORNIA' <br /> APPLICANT'S SIGNATURE V/ TITLE Field Services Coordinator DATE 207 ?o 2Z <br /> ❑ APPROVED APPROVED WITH CONDITION (S) ❑ DISAPPROVED <br /> ( 0 ( N 1TIONS BELOW ANDIOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME I q� � Jq DATE ( 1 TO r <br /> ANY DEVIATIONS FROM THIS R KLI ATIbN MU T S OMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK, <br /> CONDITIONS . <br /> 3of10 <br />