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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERIL Tr <br /> ;0e,500 0e,500 7 <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FRT TH APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: �� n O Q o <br /> I �Z,�v p _ , REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE dam. �u <br /> EPA SITE # CkG d0z-?-q 007- I PROJECT CONTACT 8 TELEPHONE # FLOYD SMITHSON (530) 478 6464 <br /> F FACILITY NAME LA FINCA N0.1 PARTNERSHIP PHONE #(530) 478 6464 <br /> A <br /> C ADDRESS 1611 SOUTH AIRPORT WAY, STOCKTON, CALIFORNIA 9520 <br /> L CROSS STREETCHARTER WAY - <br /> I PHONE # <br /> T OWNER/OPERATORDER, U.S. FEDERAL GOVERNMENT (US FOREST SERVICE <br /> Y <br /> C CONTRACTOR NAME JAMES J. HOBLITZELL I PHONE # (209) 943 7793 <br /> D cA LIt # cass A HAZ <br /> N CONTRACTOR ADDRESS P 0 BOX 30331 365234 <br /> T WORK.COMP.# EXEMPT <br /> R INSURER NA <br /> A I PERMIT # <br /> C FIRE DISTRICT STOCKTON <br /> 0 LABORATORY NAME MCCAMPBELL ANALYTICAL COUNTY CONTRA COSTA PHONEy#x(925) 798 1620 <br /> R SAMPLING FIRM EPICENE INTERPHONE 1510) 791 1986 <br /> NATIONAL <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- T (1M FSTIMATFD <br /> T 39- RSD N <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> MWITTFIMEW <br /> P <br /> L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> I A (SEE CONDITIO BELOW AND/OR ON ATTACHMENT) <br /> 1 N PLAN REVIEWER'S HANE DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN 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 OF THE WORK FOR WHICH THIS PE IT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE DATE 1 <br /> CONDITION(S): CONTACT UNDERGROUND SERVICE ALERT (USA) AT LEAST 48 HOURS PRIOR TO EXCAVATING. <br /> 2? f o wta ka �vt�2 *w.-A appo i n www f- OA- LW S+Y- 48 kamzp <br /> IK Qd"clt. <br /> I�IaM 0 aprtived � re-c1L.i z;� � lac-}" G�c� la-Io-Rq �vn <br /> y * �koaM 'FWata I Jr. ) La FvncA a#! t -t- <br /> VA, ((Spa/n��bCee for- tG�¢ reyv�ovq,Lp 0Fd�- <br /> EH 23 OGb (Revised 970/9f I 1 LiPeWa 3 i�L aiy d �y(C�(,(n�[� , <br />