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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <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 # CAC011476528 PROJECT CONTACT 8 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 /> 1 <br /> L CROSS STREET <br /> CHARTER WAY I _ PHONE # <br /> T OWNER/OPERATOR OD,I p o F?S4 0 (530) 478 6464 <br /> Y LA FINCA N0. 1, A CALIFO I ARTNF I. <br /> C CONTRACTOR NAME JAMES J. HOBLITZELL I PHONE # (209) 943 7793 <br /> 0 CA LIC # CLASS <br /> N CONTRACTOR ADDRESS P.O. BOX 30331 365234 A HAZ <br /> T <br /> R INSURER NA WORK.CONP.# EXEMPT <br /> i 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 0(510) 791 1986 <br /> iII11111111TANK 11111111111111 TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- non FCTIMAIEn nTF(;FI UNKNOWN PRE <br /> T 39- <br /> A 39- <br /> N 39- <br /> 1 K 39- <br /> 1 39- <br /> II39- <br /> II 11 I I I II I II II 11111 111111 I I II III1111111111111 <br /> P APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> L <br /> A (SEE CONDITIONS BELOW ANO/OR ON ATTACHMENT) <br /> I N DATE <br /> PLAN REVIEWER'S NAME <br /> 1111111Illlillll llllllll 1 1 11 1 1 11 lllilll 1 1 11111 1 1 1 1 111 1111111 111 l 11 Illll l 11 1111 1 1 111111 1 1 1 11 l 11 1 1 1 lllllllllll l 111 11 l 11 l 1111 l 11 <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: "1 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 <br /> CERTIFY THATE IN THE PERFORMANCELAWS <br /> OF THEWORKFORAWHICHCONTRACTOR'S <br /> ITHIRING <br /> ISSUED, I SHALLTING EMPLOYSIGNATURE <br /> PERSONS SUBJECTCERTIFIES <br /> TOTHE <br /> WORKERFOLLOWING: <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> TITLE �L DATE 01 D(A <br /> APPLICANT'S SIGNATURE: I <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 />