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SAN JOAOUIN COUNTY Environmental Health Department APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: ® REMOVAL ❑ TEMPORARY CLOSURE ❑CLOSURE IN PLACE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL FMPI OY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." Original APPLICANT'S SIGNATURE TITLE President —&p DATE I�ev�e2d1 6/3/21 FACILITY INFORMATION EPA SITE # PROJECT CONTACT Adam Burton PHONE# 415-533-0112 FACILITY NAME Holly Commerce Center LLC PHONE # 925-283-8777 ADDRESS 20500 Holly Drive Tracy,CA 95304 CROSS STREET W. Sugar Road OWNER OPERATOR Tricia Wilkalis PHONE # 925-283-8777 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL FMPI OY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." Original APPLICANT'S SIGNATURE TITLE President —&p DATE I�ev�e2d1 6/3/21 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST CONTRACTOR INFORMATION 39- 11,000 Gallon CONTRACTOR NAME Costera Waste & Environmental, Inc. 39- PHONE # 415-533-0112 CONTRACTOR ADDRESS 14 EI Vaquero, Rancho Santa Marga ita, CA 926881 CA LIC # CLASS A HAZ INSURER State Compensation Insurance Fund WORKER COMP# 9286941 FIRE DISTRICT S. San joa Uin County Fire Authority Required Per 4/30/21 PERMIT IN email from Danie Stowe LABORATORY NAME Forensic Analytical and / or McCam bell mega COUNTY ame a PHONE # 866-641-0490 / 877-252-9262 SAMPLING FIRM Environmental Science Services PHONE #gl6.417.5,961 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL FMPI OY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." Original APPLICANT'S SIGNATURE TITLE President —&p DATE I�ev�e2d1 6/3/21 TANK INFORMATION TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED 39- 11,000 Gallon Fuel Oil Unknown 39- 11,000 Gallon Fuel 001 Unknown 39- 39- 39- 39 - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL FMPI OY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." Original APPLICANT'S SIGNATURE TITLE President —&p DATE I�ev�e2d1 6/3/21 3of10 ❑ APPROVED APPROVED WITH CONDITIONS) (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) PLAN REVIEWER'S NAME �/ ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL CONDITIONS. ❑DISAPPROVED l - b DATE 0 v 21 PRIOR TO COMMENCING WORK, 3of10