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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 FRp/IM TH APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> i'l ZIXX� _ REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # CA6 I���--���(�5� PROJECT CONTACT & TELEPHONE it FLOYD SMITHSON (530) 478 6464 <br /> F FACILITY NAME LA FINCA NO. 1 PARTNERSHIP PHONE <br /> A 530) 478 6464 <br /> C ADDRESS 1611 SOUTH AIRPORT WAY, STOCKTON, CALIFORNIA 95206 <br /> 1 <br /> L CROSS STREET <br /> I CHARTER WAY <br /> T OWNER/OPERATOR PHONE # <br /> Y OWNER, U.S. FEDERAL GOVERNMENT (US FOREST SERVICE <br /> C CONTRACTOR NAME JAMES J. HOBLITZELL _ I PHONE # (209) 943 7793 <br /> 0 <br /> N CONTRACTOR ADDRESS P.O. BOX 30331 GA LIG #365234 CLASS A HAZ <br /> T <br /> R INSURER NA WORK.COMP.# EXEMPT <br /> A <br /> C FIRE DISTRICT STOCKTON PERMIT # <br /> T <br /> 0 LABORATORY NAME MCCAMPBELL ANALYTICAL COUNTY CONTRA COSTA PHONE # (925) 798 1620 <br /> R <br /> SAMPLING FIRM EPIGENE INTERNATIONAL PHONE #(510) 791 1986 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- MAT FT) <br /> T 39- {DD rtµSD 1 -7-N 1 1 <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 1111111111 FITI i i ffffffffffti ii u i i i i i i i im i i i i i mirifumn 1111 <br /> P <br /> L APPROVED /�O APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIO S BELOW AND/OR ON ATTACHMENT) <br /> N PLAN REVIEWER'S NAME IYY I/�-1/ ►1IM)WY�SjXL 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 /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PE 4IT IS ISSUED, I 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 /> (alt fo waica lvtqo' ec*wvl appowv✓mxl- o-+ (ets4-r 48 h6utd <br /> IK adAl'KCe. <br /> VIaM a,Qprtiv2d fan pece i fit (Q.�+er d�fcd la-Io-�q .� cTvl <br /> YJ�I 'J. P�v��QA , �r. , La F nca� -itl Pa✓-1�VVA5lU p I Sfzt,#ivt� <br /> cu k w� (I be �C�ov�sibC¢ fn vq p �Fd t�� <br /> kal- <br /> CS)l <br /> EH 23 046 (Revise�T19yo <br /> p.%3Il V <br />