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09/26/2002 14:17 2094683433 FIFTH FLOOR PAGE 03 <br /> SAN JOAQUIN COUNTY <LUT- cs <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,r FLOOR <br /> STOCKrON.CA 85202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT.OR PIPING REPAIR PERMIT <br /> TKIS PERMIT WIRES 80 DAYS FROM TME APPROVAL DATE. 00 NOT WRITE IN ANY SNADED MEAS.INDICATE PERMIT TYPE BELOW, <br /> _TANK RETROFIT �IPING REPAIRIRETROFIT -&UNDER DISPENSER CONTAINMENT REPAIRMETROFIY ZI9q <br /> --------------------------------------------I--------------------- ------------------------------------------------------------- <br /> _______________________ ______________________________________________________________________________________________________. <br /> I EPA SCIS » 1 PROJECT OJPTACT i TarrsHO'R » <br /> i •..._....... ______________________!_ . .... ------------------------------------------------------------- <br /> I P I PACILIIY 10. qq��yp p� p �T... ___I <br /> (.. <br /> I A ................1._.':_5.�---_- - PI-Y.l_------------------------------------------Praia»` _. <br /> AMRMS <br /> ] : _. ....�r�J t?S/t�11 1 -Ra C� - ioc l +L -L cA- P_� s2.o ' <br /> ' L I CROSS siRPPd -�'2`+F�;.t-�^ - 1. T----'---- ---'I <br /> i I <br /> ------OPER-- = b- .....----I <br /> I T I aOmc/OPaaAIDR - I Pe»BES » <br /> Y `� � �J f_C_��... S------ --------------- --C COMIC=*XE <br /> 10 •----------------- e{ pp�' Teci}_t 1"Q_( pcl ...... <br /> I R I ox------- ------- i t}• I I_o____S. -�GuJ6 -I a uc t <br /> 1 It <br /> A j•mmn®E•-s���-z.___i-.__rn____�___________________________ I <br /> 1 C I C� �� _______________i_______..___S.^.7�____G <br /> IT.___________________________________________________-___-_-_____. i <br /> 1 O 1 __._...____ <br /> IR------------------------------------------------------ -------------------------------------------------- <br /> I I I PNONe t I <br /> •---IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII----------------••--------- --••••••--------.._ ___._--.......__.________._._.......•.___I <br /> I Ta:a m » I TAN[ size POOP-� PD313IXI$ sronm x/Pvyv]aesur I DATE M mTALLM <br /> 1 1 JJ•�i7 /YZA-ter �L I I L<+SGaI N T I I <br /> I T <br /> I iP- <br /> I I J9• I i I 1 <br /> I I <br /> ---IIIf11111111111111111111111111111111111111111111111 Illllllllllllll;ll!!1 1 IIIIIIIIIIIIIIIIIIIIIIIIIIilllllllllllllll <br /> y _. <br /> I <br /> I LL I APRATveO _aPPAD W Nll CO4DITION(SI DISAPPROV® <br /> [ A l s a rrr ac smina�I f� , i <br /> I R I vlAa REVIWEP$Nane_�,11�ng1� <br /> IIIIIIIIIIIIIIIIIIIIIIIILi'Ii1 uii Ill IIIIii1 nl`TIY111144111 unullH� IIIIIIIIIIIIulllunnl I In IIIInlnnln <br /> I <br /> I APPLICanT!fir PFRPC(Y»ALL POPR IN RQORn'SA2 KITH 9AN JOPDOfJi LUfA1Y CRPLm129, 6TAT2 LAMS, AiID ln+re< A!m RSOOCAITOerd OP I <br /> I SAN JOACOIN aOEErn', FNPIR2a4irDv, ien[.Ilf DEPAR'RwerP. OELJER IXt LICare®A501T.s STC4VT URTIPIGS M TOLV t •1 CERT= I I =IIAT IH IRS <br /> PPRfOl4a310E OP TIC.IlOxx FOR M(IIX TRC3 PFTRIT L6 2650®, 1 S.mlt.RdI' LHP[gY ANY PeP3pN LC 6U01 A EIA)GHt A9 TO I <br /> I e¢Cb¢SU6IPLT'10 IAWtat'S 0.YBLTW.nbJ [ANS OP CW.LP�PNN.• OJNi3UC)TPtS HIRING pR 5U80RTRACTING SIGRATVRE fSBTIpIPS 'IF➢t I <br /> I IOI.IdIDia: •! CRNTIFY INAT IN T PIAEOW NOZ W v@ FORK EOR lGl THi6 P®UtIT 13 I$6 - 1 s:V,LL PE@ PeP9m1S 30PJECT TO I I WORM'S <br /> LTMPmSATWN LABS OP Ca.I) Lk.- <br /> I <br /> 1 <br /> 1 <br /> I APPLimav's slawuRii; OD,�S� rrEla£IS u flora. rISnP OATS I <br /> I <br /> 131WNG INFORMATION: C <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 fnr the billing by signature and date below. <br /> Name Address Phone# <br /> 1 <br />