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rr .r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> 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 /> EPA SITE # CAC001476528 PROJECT CONTACT & TELEPHONE # FLOYD SMITHSON (530) 478 6464 <br /> F FACILITY NAME LA FINCA NO. 1 PARTNERSHIP PHONE #(530) 478 6464 <br /> A <br /> C ADDRESS 1611 SOUTH AIRPORT WAY, STOCKTON, CALIFORNIA 9520 <br /> I <br /> L CROSS STREET CHARTER WAY <br /> I ( PHONE # <br /> T OWNER/OPERATORo �;jP - -i (530) 478 6464 <br /> Y LA FINCA NO. 1, A CALIFORD,I Ip . ARTNE.PS <br /> C CONTRACTOR NAME JAMES J. HOBLITZELL I PHONE # (209) 943 7793 <br /> D CA LIC #365234 cLAss A HAZ <br /> N CONTRACTOR ADDRESS p.0. BOX 30331 <br /> T WORK.COMP.# EXEMPT <br /> R INSURER NA <br /> A PERMIT # <br /> C FIRE DISTRICT STOCKTON <br /> T <br /> O LABORATORY NAME MCCAMPBELL ANALYTICAL COUNTY CONTRA COSTA I PHONE # (925) 798 1620 <br /> R SAMPLING FIRM EPIGENE INTERNATIONAL I PHONE 0(510) 791 1986 <br /> TANK ID # <br /> IIIlI11iIIIIIIIIIIIIIIIII TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK <br /> 39- - 1 non FCTTMpTFf) ffi FS FI <br /> T 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 1111 III 11111 II 11 ff111111!111111 I I I Ul i ! III II !!III 1111111 !1111!!!! I IIII III 111111 ! I <br /> PDISAPPROVED <br /> L APPROVED APPROVED WITH CONDITION(S) <br /> A (SEE CONDITIONS BELOW ANO/OR ON ATTACHMENT) <br /> N DATE <br /> PLAN REVIEWER'S NAME <br /> 11111111111111111111111111111111111111111111111111111111111111111111111111!1111111!I l 111111111111111111111111111111111111111 I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE 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 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 PERFOR14ANCE OF THE WORK FOR WHICH THIS PER IT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." ,,,,,,,,����� �hh�,� ,,,,������/�•���G� <br /> APPLICANT'S SIGNATURE: TITLE �L DATE � <br /> CONDITION(S): CONTACT UNDERGROUND SERVICE ALERT (USA) AT LEAST 48 HOURS PRIOR TO EXCAVATING. <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />