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-SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD FLOOR. <br /> STOC KTON.CA 85202 <br /> APPLICATION FOR UNOERGROUNO TANK RETROFIT.OR PIPING REPAIR PERMIT <br /> THIS PERMIT.EXPIREB 00 DAYS FROM THEAPPROVAL DATE, CO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANKRETROMT ;PIPING REPAIP/RETROFIT UNDER DISPENSER CONTAINMENT PP?AIRIRETROFIT <br /> -------------- <br /> 1 1 -TPA SITE{ .' I- PROJECT CONTACT A TELEPHOWS B I <br /> I +••______________ _____________________...._--_________-_-__------------------—__ —.599�01 q........_{ <br /> II A00-EEE .--fty;q. o—"_ 1�_____-_. ______________________________—__--------__.--_-_----.--� <br /> I, L I CROSS 6TAEET <br /> _------.- ___—_�-....--_____—____. <br /> I T I OWNR/OPERATOR i PEONS K ' <br /> I Y I _ __ CU2uvc�� - - aoi_s9_g_-D14 <br /> - <br /> C :'acnaTRAaTOA pArm C�J5�-------- ----- --- - -----uk-s =------- ---------------1 PEOR- a -----_---------- .. 1 <br /> o +--'--•----------- n ••-•-----• <br /> N ; CCtPSAACTOR ADDRESS�C( QSl IA-. CA LIC i!- QS� �'�•_ _____ ��S$tC�g.l1��IO�KAZ 1�IG <br /> T _________ _ WIC 1 <br /> R 1 TNSrnAA Ste{? uLQStA-6nzt ?_SN§l2YY�✓�C X1211 ---- ---------------------------------a 17 8(p--aEjS ---i <br /> IA I^'_________ _ —. <br /> 1 C i OTHER INPORMATICN - - <br /> 1 <br /> a I PHONE P - { <br /> 1 R -----------_--------_----------------—-----—--------—------------------------------------------------—____............. <br /> ' <br /> 1 1 PRONE F <br /> •••-illl;ItIII!!1111111111111111IIII_--__-..-...,------------------------------------------_---------------------------—......._I <br /> 1 I TANE in 4 { TAt7R-SIZE - : CHEMICALS STORED Ca MMMY/PREUSOUBLY I DATE OST INSTALLED I <br /> T 1 39- — <br /> I <br /> I A 19- 1 11 <br /> I s 139- <br /> I 7 39- 1 I I <br /> +--•1111 ril il:Ii i'I Iii H 1111 L1111111111:i117i„.1 .11',11.11„111111:IIII11.f—11111111111;11 11:111111 „111111 II iiiii{,I1I111�1 <br /> 1PI 1 <br /> L 1 - P Soso APPROVED WITH CCWI1XTXOWS) _- PISAPPROVED 1 <br /> I.A 1 ..� (SEN ArTACNMENT NiT[1 CaDDiria961 <br /> I N ' PLAN REPTE9lBks NAbffi P - � .DATE D , <br /> --III'I1 I III f: I 1 1.11 t{I" I ',..I Ii I',1111'.11:1 1111 III l,IIIII III'1 II11 L'I.',is I,I..... 11 „ ,IIII <br /> 1 <br /> , APVLICANT 1WST PERI+ L NORX IN CCORD C WITH SAW JOAOUIM COUNTY ORDTNANCEA, STATE LAWS, AND NOUN AND REGULATIONS Os <br /> I SAN JOAOCIN COUNTY, EBUIROAMENTAL TH PARTMENT. OWNER OR LICEN= AGENT'S SIGNATONE CERTIFIES THS POLLONYNa: 'I CERTIFY 1 <br /> THAT LN THE QERPORMANCS CP TWE WO.% PO WHICH TNZ6 PERMIT IH IBEUED, I SHW" NOT EMPLOY ANY PERSON IN SOON A FAWNER AS TO I <br /> BECOME SUEJECT TO WCBSEA'E COMPENSATION LANs OF CALIFORNIA.- CONTRACTOR'S HIRING OR GCBCONTRACTINa SIGNATURE CFRTI9IES TMS <br /> POLLONTNG: -1 CERTIFY THAT 0 TWO PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT LS i6E0ED, I SHALL EMPLOY PERSONS =MMCT TO I <br /> NOEBR'B CCMPENSATTCW LANG OP CALIFORNIA.- 1 <br /> j I <br /> 1 <br /> J. InRTTR111O1'R nTrEINiAmpl - Vllffi <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Nameylia73id-flav aptg&Address 00 auivio �ve�sau.loSe P'one# `fig X13-1003 <br /> Signaturerev <br /> EH230038 ,� • <br /> (revised 1131/02) <br />