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ENVIRONMENTAL HEALTH DIVISION <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 />i' <br />X REMOVAL TEMPORARY CLOSURE �% CLOSURE IN PLACE <br />EPA SITE # CA8210020832 PROJECT CONTACT & TELEPHONE* Keith A. Tallia 209-754-1808 <br />F FACILITY NAME Bldg. 647 - Sharpe Depot, Lathrop PHONE # 209-982-2094 <br />A <br />C ADDRESS D S t . <br />I <br />L CROSS STREET S o . Crane <br />I <br />T OWNER/OPERATOR DDRW Contracting Bldg S-4PHONE 0 <br />Y Sharpe Facility, Box 960001, Stockton A 95296 1 209-982-2094 <br />C CONTRACTOR NAME Oil Equipment Service ( PHONE it 209-754-1808 <br />0 <br />N CONTRACTOR ADDRESSa n' Andreas, T C A 95249 CA LIC * 323417 CLASS A- H a z <br />R INSURER State Comp Ins. Fund WORK.COMP.# 265057 <br />A <br />C FIRE DISTRICT Sharpe Depot - In house,N PERMIT # N/A <br />T <br />0 LABORATORY NAME GeoAnalytical Labs, Inc , Modesto PHONE # 209-572-0900 <br />R <br />SAMPLING FIRM Condor Earth Technologi Inc. PHONE # 209-668-9234 <br />111111111111111111111111111111 <br />TANK ID # TANK SIZE <br />39- <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />1111 <br />P <br />CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br />L _ APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br />ASE TTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS MAKE ID DATE _ <br />lllilllllilllllillli 11111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WI-�1 SAN Jin IN 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 MOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION L#14 OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERF2!W OF THE WORK FOR WHICH T PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF NI <br />APPLICANT'S SI TITLE President DATE 5/19/95 <br />eit a <br />bLA <br />EH 23 046 (Revised 7/10/92) Page 3 <br />