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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 /> JLCROSS <br /> A SITE # CAC001476528 PROJECT CONTACT 8 TELEPHONE # FLOYD SMITHSON (530) 478 6464 <br /> CILITY NAME LA FINCA N0.1 PARTNERSHIP PHONE 530) 478 6464 <br /> DRESS 1611 SOUTH AIRPORT WAY, STOCKTON, CALIFORNIA 9520 <br /> STREET ARTFR WAY PHONE # <br /> T OWNER/OPERATOR <br /> Y LA FINCA NO. 1, A CALIFODNIA PARTNE'S�Io (530) 478 64 4 <br /> C CONTRACTOR NAME JAMES J. HOBLITZELL I PHONE # (209) 943 7793 <br /> ° CA LIC # CLASS <br /> N CONTRACTOR ADDRESS P.O. BOX 30331 365234 A HAZ <br /> TVORK.COMP.# EXEMPT <br /> R INSURER NA <br /> A I PERMIT # <br /> C FIRE DISTRICT STOCKTON <br /> 0 LABORATORY NAME MCCAMPBELL ANALYTICAL COUNTY CONTRA COSTA PHONE # (925) 798 1620 <br /> R SAMPLING FIRM EPIGENE INTERNATIONAL PHONE #(510) 791 1986 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- I. onn FCTTMATFD r)TFSFI UNKNCWN PRE 197( <br /> T 39- <br /> A 39- <br /> N 39- <br /> 3 39- <br /> 39- <br /> 39- <br /> FIIIlll llllTTlll I I I I RI11111-II ��11-1-iIII ITIT11 HIIIIIIIMMM <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N DATE <br /> PLAN REVIEWER'S NAME <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY THE PERFORMANCE OF THE LWORK E FOR HWHICH I THIS PERMIT FSNER ISSUED, ILICENSED ASHALL SNOT GEMPLOY ANY NATURE TPERSON IFIES T IN SUCHHE OAI KANNERI ASETOI FY T IN <br /> 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 15 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> CONDENSATION LAYS OF CALIFORNIA." <br /> 0:1 ft-t4j <br /> APPLICANT'S SIGNATURE: TITLE 1.� 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 />