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F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />ENVIRONMENTAL HEALTH DIVISION <br />.wL 15 PH 1:33 <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />X_ REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # CPROJECT CONTACT & TELEPHONE # TA I T & A <br />.? tt916) 635�L 920 604 834 Chester BenneSSOCIA -244 <br />FACILITY NAME ANASTASIO' S AM/PM MINI MART PHONE # ( 209 ) 835-1605 <br />ADDRESS 3425 Tracy Blvd, Tracy, CA <br />CROSS STREET Clover Road <br />OWNER/OPERATOR PHONE # <br />Jack Anastasio (209) 835-1605 <br />CONTRACTOR NAME Golden West Environmental Builder Inc. PHONE # ( 51 0) 447.-2-484 <br />CONTRACTOR ADDRESS 567 Exchange Court CA LIC # 432103 1 CLASS <br />�j{i;/jpKGj 1 M1� <br />INSURER <br />q1 I �I WORK.COMP.# 001486-92 <br />Wi <br />FIRE DISTRICT TR�aG`I' til btSTRiG'f PERMIT # <br />T PHONE # <br />0 LABORATORY NAME sequoia Analytical, Concord CA (51 0) 686-9600 <br />R <br />SAMPLING FIRM Roux Associates PHONE # (51 0) 602-2333 <br />— <br />TANK tlllltilliI lllllllllllll <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />3 39- — 3 ^� u- ar Un ea a aso in iun'-19/2 <br />A 39- / i..�-:.rr;�-e n ea e as <br />-17 <br />N 39- - <br />6000 �^ ' In ea e aso line JLri�-1 972 <br />K 39- 8 000 fie- V aso (A r- JUng -0 — <br />39- <br />1111 T <br />P <br />L _ APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br />A (SE ATTACHME WITH CONDITIONS) <br />N PLAN REVIEWERS NAMEIII GATE <br />OATE <br />Illllllllllilltlllit <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUJN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA /J <br />APPLICANT'S SIGNATURE: oe <br />TITLE ,Q� QST'°'Sfrc-hDATE S' S "i3 <br />fu, <br />b YIZ( <br />EH 23 046 (Revised 7/10/92) <br />�il'GIC 1 G ^J l/�/�' / t r <br />Page 3 <br />