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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPART _NT <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />US <br />HIS PERMIT FOR PERMANENITTEMPORARY CLOSURE OR ABATE oNMENT IN PLACE OUNDERGROUND <br />DO NOTWRI E IN ANY SHHADEDAREAS.IN INDICATE SUBSTANCES <br />E PERMIT <br />THIS <br />STORAGE TANKS) EXPIRES 90 DAYS FROM THE APPROVAL <br />EMOVAL El TEMPORARY CLOSURE Cl CLOSURE IN PLACE <br />FACILITY INFORMATION <br />�%f — 2-3l � <br />EPA SITE # I PROJECT CONTACT / - L' t PHONE # 2t <br />FACILITY NAME I <br />ADDRESS r' <br />CROSS STRIFE !/y �/ Co4�'%7 ` <br />OWNER OPERATOR <br />CONTRACTOR INFORMATION PHONE# LILY` <br />CONTRACTOR NAME /I i !/) j CA LIC # <br />co <br />11 % <br />CONTRACTOR ADDRESS 677 <br />INSURER fslll �1 N< r/ rutin L ��fC- fir' WORKER COMP# 1— �`' <br />/` rjl% G PERMIT # >✓ _ <br />FIRE DISTRICT G COUNTY Sfiw!1 (rr PHONE# 2-.9c �' <br />LABORATORY NAME G ° C� L PHONE # Z!' <br />SAMPLING FIRM b, �� r <br />r L DISAPPROVED <br />❑ APPROVED PROVED WITH GOND1TiON(S) <br />EE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />DATE <br />PLAN REVIEWER'S NAME <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTEIiD FOR APPROVAL pR10R TQ COMMENCING WORK. <br />_ CONDITIONS:1 A A <br />23 046 (REVISED 3!15102) Page 3 <br />