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SAN JOAQUIN G OONTY <br /> ENVIROigMENTAL HEALTH�DEPAk rMENT <br /> 304 E WE®CR AVE,3RD FLO <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREA5. INDICATE PERPAIT TYPE BELOW: <br /> ------_•STANK RETROFIT /PIPING REPAIRIRETROFIT _UNDER DIS TENSER CONTAINMENT REPAIRIRETROFIT <br /> ♦-^__rEPR SITzIN ---^-_�----- __- ------- -__--�_—_� --------^----------------- ---* <br /> _ _ 1 PRDJV-CT CDNTACT & TEL—ME - <br /> F r <br /> FACILITY`4At>E�— - --- _`----------^.__-- -------------------------^---- -------------------- <br /> ----- --- <br /> R *--- - -- LQ,. I�� '��`-'-�a------- ••_-------- PHONE N <br /> -_ <br /> L t CROSS STREET __z <br /> i T { 0r7NER/C?--------- <br /> C ; CONTRACTOR NA{�Z — <br /> ___ <br /> j <br /> I e +-----__-_-------- `)D- -�-�' J!_+.2lSs3r_ ............ <br /> PHOnye <br /> I h I MNITIRX"POA ADDRESS ('� J -j--- <br /> T +-- I yr 7E ZCA L'1c---- ----- CrrASS I <br /> I ---^------------- - _ 11La 5- -------------------- <br /> - 3 I _ p <br /> ^�_ ^0S <br /> ' R 7JSURER �� "-- <br /> ' WORti-C�:�hLfl. <br /> I C I OTI-TR INFOkhtATIox — <br /> --------------— --_----___—___-____r____________ ' <br /> N£ <br /> _-_-- _______ <br /> TANK IAN �.___r______________^ -___-__ <br /> TAW 3:ZE CHPM_TCA'Ls STORED CVARENTLY/Pa��IPUSLY LATE UiT INSTALLED <br /> I - <br /> A i 34- <br /> 39- <br /> 39- <br /> 39- <br /> 1 <br /> 9-39-39- I <br /> _APPROVED " A2PFOVED WZ%Y.CONDITION(S? 1 DISAPPRCVELi <br /> A ' (SEE ATTACI MLhr, tel <br /> + TH CpNDITI0;8) <br /> N ?LAN REVIEiPS s -IA3'E <br /> ,Ili <br /> APPLI:.A.N MUST PE3FOPM ALL WDFW IN ACMP5AnC5 WITH SAN uIN COrNPY ORDINANCES, STPqE LAWS, AND RL7.F,$ AND PEGULATIONS GE' <br /> SAN JOAQUIN CMUr1TY1 EMixROiT!EtITAL IjafLTH DEPARTIC-NT. OWNER OR LICEgSED WENI'S SIGNAT� CP-kZXFIE5 T!-Z FOIMWT_Nr: "I CERTIFY THAT IN T14E <br /> FMp•OP1W4ICE OF TFZ 1vU(LY ECR MICH THIS PERMIT IS ISSUED, I SHPTS I= &W-OY ANY PERSON I SUCH A MANNER AS TO <br /> JE <br /> BFC=—T SUBJECT- TQ WORKFIR'S r..GMPENSATION;..,As OF CAL IFt7RLdIA." CCNTAACMA'S lLRING OR .1 S aPITURE CERTIFIES VHS <br /> TOLL6WING; "I CERTIFY THAT ,Tpt T}IE PER P'-X MCE OP THE WORK FOR WHICF! TH_T5 Z-EWAIT :S ISSUED, I SHALL EbffLOY PERSONS SUSSECT TO ➢10RIM.'S <br /> C^-M„'ZN3A7-ION LIVS OF CA141MRNIA,^ <br /> A?FIICA747'3 SIGnwTUPE: TI':t£ GAPE <br /> tf , <br /> BILLING INFORMATION: j <br /> Indicate the responsible party to be billed for additional EHb stiff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, <br /> the party must acknowledge this responsibility for the billing by '9nnature and date below. <br /> i <br /> Name , �� , Address <br /> :' <br /> . r z66 �',gAe Ph- <br /> one# <br /> -------------------------------------------------------------------------------------------------------- <br /> rTrTr i rr Ann n.nnr r..11 <br />