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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> TANCE <br /> ETHE XPIRESM90 DAYS FROMNTHE/APPROALYDATESURE OR DO NOTWRITEIN IN PLACE OF UNDERGROUND ANY SHADED AREAS. INDICATEAPERMOITTSTYPESSTORAGE TANK <br /> BELOW: <br /> _x REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE It CAC001476528 PROJECT CONTACT & TELEPHONE It 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 /> ( PHONE # <br /> T OWNER/OPERATOR OWNER, U.S. FEDERAL GOVERNMENT (US FOREST SERVICE <br /> Y <br /> C CONTRACTOR NAME JAMES J. HOBLITZELL I PHONE # (20g) 943 7793 <br /> O CA LIC # CLASS <br /> N CONTRACTOR ADDRESS P.O. BOX 30331 365234 A HAZ <br /> T <br /> R INSURER NA WORK.COMP.# EXEMPT <br /> A I PERMIT # <br /> C FIRE DISTRICT STOCKTON <br /> 0 LABORATORY NAME MCCAMPBELL ANALYTICAL COUNTY CONTRA COSTA I PHONE # (925) 798 1620 <br /> R I PHONE #(510) 791 1986 <br /> SAMPLING FIRM EPIGENE INTERNATIONAL <br /> 111111111111111111111111111111 TANK 512E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK ID # UN NOWN-PRE 192-1 <br /> 39- 1 000 FSTIMATFD DT FSFI <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> IIII II II11111111111 I I I I III 111 III II11 II I I II II 1 <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) /� <br /> N DATE Ia-I3-Qcl <br /> PIAN REVIEWER'S NAME <br /> III111111111111111111111111111111111111111111111 illlillllllllllllllllilllllllllllllllllilllllilllllllllllllllllllllllllllll <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 /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PE IT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> CONDITION(S): CONTACT UNDERGROUND SERVICE ALERT (USA) AT LEAST 48 HOURS PRIOR TO EXCAVATING. <br /> b wVJU I n5peCtLmi 0.p po I vt fi CJ CaOsf- 4 S h Okr s <br /> I aGWcL4/1 U . <br /> a-I O- aq tl <br /> W�1l�avh <br /> 1,p.Fi-A.ca � I w (� Ix (IV 1751 4u r�vv aj, a Wi 2 <br /> 111 , �' d L <br /> EH 23 046 (Revised 9P/9b1 —_ " " v <br />