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Oct 15 04 10: 49a [20 794-0112 P. 3 <br /> 10/14/2004 16:09 209433 FIFTH FLOOR PAGE 03 <br /> SAN JOAQUI14 COUNTY <br /> ENVIRONMENTAL, HEALTH DEPARTMENT <br /> 704E WEBER AY6,MRP FLOOR <br /> sTocKrm,CA 0:202 <br /> APPIJCATION FOR UNDERGROUND TAW RETROFR.OR PPM REPAIR PEF0IRT <br /> THIS FERMR FIRES 00 DAYS FROM TWAPPR04A4 DATE D0 NOT wFW2 N ANY SFwDED APE/u-INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFITPIIDNG REPAINW7ROPIT�.._MER D1S OMR CONTANM'L REPAJNRffrF4'FT <br /> ___________ ................... <br /> .....____._.T____________________________________________________ __ <br /> ___I-IDA sacs Y I Pw�• MPIACT A TYLU2=9 0 _ _ �7,..,c� p� .��7-I <br /> P PACILITT 1PWC 1 `� Y• '�/! /6 Lam'" S� J <br /> _ _ _ _ _____________________________ <br /> 1 1=::a: xoP '---- - ---- <br /> j c I AocncaF <br /> IL I Maas aTRsr .....------........ ----- - ------------------•............ <br /> .............................................. <br /> I ---------------- I flt0np ! I <br /> 1 x 1 vYrut/oeeewroR \` I <br /> (� ( PFgRc a � 7rfy Q��_ ___I <br /> I Y I [IMLMCI.OR AOOYEES \ �U •-�W S?V '�;pv�._-_I.d L C.�..af L`iL� ...� C.M.P_ OTr4.............I <br /> 1 T .._.-----•---------------- / CEJ I RRJRE.COMP.R <br /> I <br /> I A R I 1.IYSORER____e?C ..��D_4t0--�L.�-k21-1��u��.-- ____...._I_-------_------------------------------- <br /> I C ....___PLRCR <br /> 1 x .. plTOnIdF •.................................................. <br /> .................._._______ <br /> I Fv--E A <br /> 1 0 ; _______________________________________ <br /> _________________________ ------------------------------------ <br /> 7 p _ I PppyY Y <br /> -. ............ i <br /> ........................................ .__.. ... <br /> �--•II Illll 11 l lilul III IIa1�111111171I 11•-•--�-- TANK yIEE � I MI¢RIQLa STORIa)LVRY6TILY/DREPYWSLY I aAZR 1101 aiSTAL44T <br /> T I )P- I i <br /> I A )P- <br /> In1 )7• i I <br /> I FII la• ' <br /> 19 1 <br /> :...11111 I 1 L Iu�i r ., „ II, I .7J 11111 1,177:111, 1 II. I:II1111,�� <br /> C I TSAFFRa <br /> RPAo Rpv��rI�tl F 1 151 OPRZI-c) <br /> I P I PGM REPILy SP9 1111717171,1 L1 ;11111 , , ;1I 11111i <br /> •.--11111;11111111111 M1 11 <br /> 1 _ <br /> I APPLTOM"C NVYS PLRlOYN ALL PORK SN ACOORaAWLL PITR MAP iOAoaIR CV PIT' OROIRMCl.>.. STALL LAYS. ARD WE MLO piOOfdTTOn9 " <br /> I IS,.IMCRIFY OSUIIST. FSIPZYOPSt®PTIM, M%=MEW TPMT. PMP oR Ll SM M y-`I Y AF®R'pP6klaPll RAF 911MI[A MIM AS CE"'"� i <br /> ' TE11T IP WE PmPOFOWILS of WE WORx POR WHIM SKIS 1!ERDT IS Isam, ICSir.sxORA1VRY cu'IlFiif TJIR <br /> I BCCan Saa12CT M WOUM, COWP@ISAYTW LAWS Of CA4T""ZX.• LapxMLTOR•5 YYp2Fq W aWCNYUI <br /> I IW.iWzNQ. 'I L'MITIIT TWAT IP WE mfoRNApCE OF WE NWFR roR WrM 'IRIS PSRNIL IS ISM=. 1 anAl,i OIPLOT PCEaOIIS 6JIICT To I <br /> 1 10AIRM•S CVFWOSAT10R LAMS of OAI.IIORRA.• <br /> I TI'[LS «m• � <br /> I APPLFIANT'S 91 oNATOREI ' <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payme <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. propel <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Namep? rte, Address I 4a Phone# 1yy -5L <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />