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Sep-02-04 10:06am From-Gettler-Ryan Inc +9166311317 T-360 P.002/004 F-279 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,�u F40OR <br /> STOCKTON.CA OS202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> TRIs PERMIT EXPIRES 90 DAYS FROM THE APPROVAL OATS. DO NOT WRITE IN ANY SMAOEO AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT _PIPING REPAIRIPATROPIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> _______________ ..-.._._.___..-._._-____________--_-__--______._-.-__._.__-____________.___-.___._._.__.___._____-__._- <br /> 1 91A SITE P ,Ply I----------------I wm�Eel-Lealr. & =iPmose E---- C/-'r'---"'�-7__ Yy2 i <br /> 1 •------------------•--- ........... <br /> I N' I FACILITY-Nle l -- Y <br /> .r. I PHowtR <br /> rMIRESS <br /> aI A------ ------+EE-- C--- ---14k- ......... •------------------------ --. ....... .... <br /> L I CROSSSIR= <br /> V-1 <br /> I x ------- ---- `• 1---�e----.. <br /> C-her!:y--------------------------------------- <br /> ------------------------------------------------ <br /> I T OWNER/O2em= PHOtA » I <br /> Y = ---------- � 'r!r c_:f ''' !?.Y...S.. ---_s-7------W ------- <br /> 0 1 -------------E /�H%er _ . -- -- - / `x'17 E13 7 26 <br /> +- 1 PIwIg > -I <br /> T N I CONTNACTOR ADORE49 CA LIC M I OV+^+5 <br /> x •----------- ------ �/tY4 ��Jd C`'''r'—��°-------- ----- --------22079--------•- <br /> 1 1-r7_f.� NSRROCMP.R Cc ,2� E� 1 <br /> ------------------------------ 1 <br /> 1 C I O=R TNM MATIO- I i <br /> IT --------------------- reE7n__.�et��a3trv, -Ga .. 93 .7.0...-..-------------------------------------------I <br /> Cc�; I PRONE R ; <br /> ----IIIIIIIIilllllllllillin llllllil---•----------------------- ------------------------------------------------------------------I <br /> TAMC ID P I TALAR SIZE 1 CHEMTCALE EIOFIM=111INTLY/PREVIOUSLY I OAIP OSI MGVX 2D I <br /> 39- <br /> T I39• 1 I <br /> A NN" <br /> IN139- I _I <br /> Irc 139- I <br /> I 139- I I I I <br /> I 13A- I I I I <br /> _._111i11111I11111 n llllllllllllllllllllllllll llilllllilllllllllilll lillllllllill)111111111111111111111111111111111I111111111111f1 <br /> P 1 l a(C <br /> I L ADPImPQ3 �/ AIPROVEp wiTN CO�STS(W(Bl �DFBAPPROIR(1 <br /> 1 A I.WIT- RS C4 ? 4 <br /> 4KMIMI ODITIONS1 IFTey DN PIAN <br /> -II IIIIIIII IIII III 1111111111111111111111111:11 MI 11i11IIIIi Ili11111iIIli 111111 IIIIIIi INIII IIII IIII iI w filmIIIIIIIIIU <br /> I <br /> I APPLICANT wt= PR Mw ALL NORrc IN A=AaMIC9 RiM STN ]OTLOIN ODUNTY ORDIN?W=. 91ATe LANA, A RDLRR AND RNGVIATXNE OG I <br /> 9 .10AXIN D3UITLY, ENYIROM49P7AL HEALTH DEPPRMENI. ONNER OR LICTno XMIT'E SIGMTME CERTIFIES THE FOL1641M: •N aniN'Y I I THAT M THE <br /> PERFORMA M JP THE NORK FOR NMICH IRIS PERMII IS ISSUED, T SHALL NOS EMPLOY ANY PZASDN IN NCH A MINER AS TO I <br /> PEOOM9 EMncr -M RORI(ER'4 tIUiPEN.A1'ZDN I sof CALIPORNIA.- LON1'RACWk'A HIRIIW oR EuE�= %rGNATORE CERTIFICL ME I <br /> POLIORIDR: "I CERTIFY IHAT IN 17Je PLRNORMAN E OF'THE RORK NOR RHTOM THTS PERMIT i8 ISSUED, I SHAU EMPLOY P2RSONS EtW2CI TO I i NOAKER'9 <br /> mMPeiSRZICH W'15 or fN.iPoYiN1A." <br /> I I <br /> 7 I <br /> )� I <br /> TPPLICNNI'S SICTAIURPtIIL9 1 _ /1.r'C a.y DATE <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> _Phone# <br /> 1 <br />