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�11995 <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT �lC� tTH <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 />_.&_ REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EH 23 046 (Revised 7/10/92) Page 3 <br />EPA SITE # CA8210020832 <br />PROJECT CONTACT & TELEPHONE 0 Keith A. Tallia 209-754-1808 <br />F <br />FACILITY NAME Bldg. 647 - Sharpe Depot, Lathrop <br />PHONE 0 209-982-2094 <br />A <br />C <br />I <br />ADDRESS D S t . <br />L <br />CROSS STREET So. Crane <br />I <br />T <br />OWNER/OPERATOR DDRW Contracting Bldg S-4 <br />PHONE # <br />Y <br />Sharpe Facility, Box 960001, Stockton, CA 95296 <br />209-982-2094 <br />C <br />CONTRACTOR NAME Oil Equipment Service <br />PHONE # 209-754-1808 <br />0 <br />N <br />CONTRACTOR ADDRESS a n Andreas C A 95249 SbU <br />CA LIC # 3 2 3 417 <br />crass A- <br />T <br />H a z <br />R <br />INSURER State Comp Ins. Fund WORK-CONP•# 265057 <br />A <br />C <br />FIRE DISTRICT Sharpe Depot - In house PERMIT 9 N/A <br />T <br />0 <br />LABORATORY NAME GeoAnalytical Labs, Inc. Modesto PHONE # 209-572-0900 <br />R <br />, <br />SAMPLING FIRM Condor Earth Technologies Inc . PHONE # 209-668-9234 <br />111111111111111111111111111111 <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- 55 dal 1 nnG Ili PSA Iinknnwn <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P 1111 III I I if <br />L APPROVED_ APPROVED WITH GOIDITION(S) DISAPPROVED <br />_ <br />A ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS DATE A <br />IllllllllllllllllillIIIIITMIII11fill III I III I III I III 111111119 <br />APPLICANT MUST PERFORM ALL SARK IN ACCMAMCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAOUIN 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 BECCME <br />SUBJECT TO WORKER'S COMPENSATION L#4 OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERF ORMAN OF THE WORK FOR WHICH T PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF I <br />::::APPLICANT'S SI TITLE President DATE 5/19/95 <br />eit a <br />EH 23 046 (Revised 7/10/92) Page 3 <br />