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08/18/2,005 14: 53 2094683433 EHE, PAGE Ivy: <br /> NWRONNI I+ NT. L HEALTH DEPARTMENT' <br /> S AN JOAQUIN COUNTY <br /> APPLICATION FOTO UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMiT FOR FCRMANEN11EMPORARY CLOSURE GR AEvNCIONMENT IN RLA'E OF UNDERGROUND HAZARDOUSSUBSTANCE-- <br /> STOiRAGE TANK($)EXPIRES 94 DAYS FROM THE APPROVA.+_DATE, DO NOT WRITE 1N ANY SHADED AREAS- INDICATE PERMIT TYPE_ <br /> 0 REMOVAL TE 14PORARY CLOSURE © +CLOSURE IN PLACE <br /> FACILin' INFORMATION <br /> EPA SfI E# _ _ SRO,IECT CON TACTQh rj 20 <br /> yNd�af PH <br /> FACILITY NAmE--Fox wjdp Circle k _ PHONE7V0 G <br /> ADDRESS _ -h - <br /> CRDSS STREET kv <br /> c�wNeRCPTa�R t a ' C far, t-e� F+FiC3N1=# s _ 3rs <br /> Z.. <br /> CONTRACTOR INFORMATION <br /> CON)TIRACTOP NAME 'tY ._'Z'vt PHONE#fG? <br /> CONTRACTOR ADDRESS 1 f 7!t-7~A S a+±��1��C�.4tn �� Q�1 CA LIC# 'I I 175S-1 CL,ss ,4L <br /> INSURER _____ WORKER COMP# 01-7'466 �8� __---------- <br /> FIRE.E1I$TRICT ►J�l- -__ - PEFZMIT# <br /> LA,EORATORY NAME %.11 fL. 11111N _ PHONE# ---� <br /> SAfv9PL4Nw FIRM PHdNE# <br /> TANK INFORMATION <br /> TANK IU# TANK SIZE TANK CONTENTSS( RESENT& P.ASST - DATE INSTALLED <br /> - <br /> 30- <br /> 39 <br /> APPLICANY MUST PERFORM ALL%YORK IN ACCORDANCE WTH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RVL9&AND <br /> REGULATIONS OF SAN JOA4)UIN COUNTY FW)RONMENTAL HEALTH DEPARTMCCNT, CaVVNER OR LICiiNSiD ACENTS SIGNATURE CERT PIES 'HE <br /> POL40WINU: `I CERTIFY HAT IN THE PERFCRMANCt OF THE WORK FOR MICH THIS PERMI i IS ISSUED,!SMALL NOT EMPLOY ANY PER$ON IN SUF:rI <br /> A MANNER AS TO SECOME $.IBS15CT TC VWRKER'S COMPENSATION LAWS OF GALIFGF:NIA," 0CN1`AA0TOR'$ HIRING OR $U6C0NTRAGTNG <br /> $IGNATUIRE CERTIFIES THE FCLLOINING: "I CEPTIFY TF Y 7 IN E PBRFQRMANOE OF THE MRK FOR WHICH' THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO%%ORKBA' CCMPRE.sA.- ht' V Or-GALIFORNiA" <br /> API^L ICAT,ITS$GNLATUR TITLE SC us/' DATE I? <br /> -© APPROVED —DVEU WITH CONDITION(S) - Ll DISAPPROVED <br /> ;SEE CONDITIONS BE'_OVt AND/OR ON ATTACHMENT) <br /> DATE <br /> PLAN REVIEWERS �. - --- <br /> ANY I71=VIAT±ONS FROM THIS APPLICAfJON1 MUST EE=.SUE�Nll UIZO-r EHID FOI2 APPROVAL El_tl_gR TQ COMAMENCING WO RK. <br /> CONDITIONS, - <br /> EH 23 046 (Revised 8f9,'06) 3 <br />