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074/05/2006 13:38 505-2B6-0990 ATEAM CONSULTING PAGE 01 <br />RPR 04 2001 11:33Rt•NP LASERJET 3200 • P,1 <br />2 - <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />ODS! NEBERAVE. Ob FLOOR <br />STOCKTDN, CA 13401 <br />APPLICATION FOR UNO ERCROUNO TANK RETROFIT, OR PIPINO REPAIR PERMIT <br />THIS PERIAITEKPIRES b DAYS FR HE`E AAPtPRROV CATS DO NOT WRITE IN ANY SHAD ED AREAS. INDICATE PERMIT TYPE BELOW. <br />_TANK RETROFIT_ IPP IRO REPAI /FIT HOER DISPENSER CONTAINMENT REPAIRMLTROPI'[ <br />...............--_--__.._.__..-.----_______.._.......___._............____._... _. _ Y/ _.. ____________........ /// /�� <br />APA ... / ..... CONTACT A Tttv'9 nOxS-IMtKF_�,^,()Gy ip �_!/6 IK= 13= <br />T� __. <br />v 1 [ACTt ITY PMIS - _ - --IxON�_.... __ ____________ <br />L ] SZ <br />%_ e.e " " .l-_----___-_._ _ <br />C AODAFS6 <br />L Ot... .TNER = .... <br />------------ <br />x-o <br />I OYNAR/OPRAATOA ! PHONE R <br />C --------I-MINT"MR EAM� t - _ '._I -PRONE / .- <br />__ __. L•U(•ry <br />X ................pSEPj`E ,.'?o�ll.-------'-==AA•_� :61 _ <br />ALEXIO <br />T •____.-._-_. _ALEX_-J..JJ``••'� <br />R IWAVRBA •_••- /• /��I7j![�' ��[yy]TI{��J��,()y <br />A -------- ��'��✓�\A'•r j -_ ---•------aXP.P <br />.. .AAAA _....... _...•_ �7'/•�-,Yl+ <br />" OTKBR C PO)aATION ___. <br />T--------------------------------------------------------------- ----------------------P_-_--. ------------------ -.._............ <br />0 ; PRONO R <br />8 ..............----------------------------- ...................... ........... ........y ................................. ....... <br />: <br />DROPS P <br />TANK LP • TANK OUR 1 OUIXICALE STORED CONAW LY/PAEVtOUALY I OATS UST INSTALLED ' <br />I A ]9• I <br />19 <br />]]- II:I..:: II:!;II:IIIII1111:: 11111;; `II IIaI:IIIIN]IIIOI TIOXAa ll tl ll: I::::'' I l l l: lTS <br />�'l! AAI,,: IIII I:: I; :; I:: <br />A-: }LAN Aiv 18YATtB NAVA ,� N ON1A1 I' DISAPM�ROVKOi� --. <br />1 4 1 0 PPRDY D TN CDBDITI <br />'i. III;, I:II:II1� I, :; j;;illl lli li;ii) II; lillllil <br />APPLICAWT MOST POPOAM ALL YORK IA ACC.OAEANCZ YITW SAN JO,,jN = MTY OROLKANCEA, BTATN LANE, ANO RDLVI An OSOULATIONO Or <br />1 SAW JOAOVIN Co +y' SM•JAOMME"TA NSALTH ORPAATRBBT. OYYLTI OR LI MEAD AGENT'S IIOHATDRR COATIPIES TNR POLLOYINO- ^: CERTEPv <br />'E)uT IW THA PKK[OA]IANCS OP THE YORKRON WHICH TRIS ?OMIT IS ISOM, I SHALL BOT BMPLOY ANY PEABOP DI ]UCH A }CW ARA AP TO ' <br />SEOOKA DIUN T TO IIOAAHR'E COMPBRAA LAWS 0P CALIPOAMIA!- C'oarTRACTOR-E IIEOEITO OR APEmrt mrm A10NATORE C01,21rta6 Twig <br />POIAgW IRO: IQ•I CIriRTI RKANCO OF TWO YORK Lill WHICH TRIS PBRNIT IS IAawpD I ANN" RNPLOT MOM BuYJECY TO <br />WOAA'L COXPANSATI 0 CAL <br />T <br />ADTII CAN]•e ElONATUl1A; TESLA\\��) J f yA?C, i•- ('�- �Ae <br />.......................... .------------------------------------------------------- ____............................................ <br />.., <br />BILLING INFORMATION: y04%1 We et*r] <br />Indicate the responsible party to be billed for additional EHD staff time expanded 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 />Name:guy Y� *R'('C4 _Address -74T7 D,ck Cal -Ek Phone # 1�/� 3z%� <br />Signature i LY11iJ z0.�6L1�- <br />Ts3 ((C <br />(- <br />EH230039 <br />fl.IDb2.e_ c <br />(revised 1131/02) A�OE�' <br />