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- -- Fv♦rtulm u,I r� rcr� n �ruc w <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 704 E WEBER AVE.3' FLOOR <br /> STOCKTON,CA W202 <br /> APPUCATICN FOR UNOERGROUND TANK RETROFIT'.CR PIPING REPAIR PERMIT <br /> THIS P!RMIT EXPIRES 90 DAYS FROM-HE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS,INDICATE PERMIT TYPE 99LOW' <br /> TANK RETROFT PIPING REPAIR/RET - VNOER DISPENSER CONTAINMENT R6PAIFVRETROFIT - - <br /> -_._-_-__--..---.. — yn <br /> EPA SITE Y iROS£CT G7i+:AC: & TELEPRONE R ..FA _ _. 33--------- <br /> I <br /> __-_ - __ _____ ._ _ _ _gaj_ ___ <br /> a sAC2L::Y 11A1Sf�__-____..___ + _ _ I � N <br /> IrMq. <br /> : . ---- ......L.l <br /> ___________________________________ <br /> LQrrr�./ d � ------ --- _ <br /> ....... <br /> I ORY-'£RfOPSRATOR I PRON9 <br /> lie�_ _ �-Cret'i9f�! <br /> ;;.y�-----.--- -- <br /> ------------------------ <br /> ® <br /> a _(tri l- riVr. nmc± l._�irl�c S_ _...!_----R_- 46Y <br /> 5/50 <br /> Y CCVIRAC;OR ADOR89S _ _ A , ? C.A95 , <br /> 7 <br /> OTN:.R :NTVR.`V1T:CN <br /> ..................................................................................... ........................................: <br /> ?Pius Y <br /> - <br /> I ?NONE 1 <br /> •.•-'.ill'::.I'.I""''.:III' <br /> -----------------------------------101,---------------------------------------------------- <br /> - .._------------------------ ------------------------------------------------------------ <br /> om <br /> TAXK :0 6 R DISE CRL3 $'IORSD C'Rk'a01T'.Y/FR£'1ICUE_Y Dx/T Pi9TALLn <br /> Lt• Jf`-'./n — i �Prd�Q� #�'� y <br /> - l3- I <br /> A 7P- <br /> S Is-- <br /> +Y.- <br /> :9- <br /> 19 II IIt T III; il :."77 <br /> a??vev- Ae^t99,v H:-:t :cwL::ea I31 oca->PRC+w <br /> ;SZE ATTACwm+ <br /> Y ALAN a,ry::.AERS `TANS <br /> A)PL:_'?1C M.f3T PSR eGRv A,,,- a'CR¢ ::1 aCL�.L�R�G LILY. 3X:1 a AQU:-`; COCti'^.' JPA:NA::C3. +TACE i.AN4, A!R) RZ£5 A1:] .2E04^.AEI085-777777777 <br /> RT <br /> JHvt'R __ C:C:.V9IJ AGZIT"a ':^w1A:VAZ CERTITLT9 aIL '--LOHI`IG: : CYT:"! <br /> CXP.T :SV YE PERF^AH:NC_ OP C WORK -OR•'lx.i Cm T 0 ?`-Z.4I" :3 :u'u'•JF', i `Y _ \�- -_.?LO? :w, PERSON :.v 9[,v[ A "hNMZ. AS <br /> 3EL•ONi. SJ2JEL; 70 Ht;RIER'3 �+'.PL•13A::CY _A:+S : ^:t'.:,omm.' COziT AC:OR'9 i:R:\� OR 9C8Cbt:Rl.CT:NG 9=ATCR:. =.F:E9 _ <br /> ^_RT:i! :. ::! +CRR FOR NY:C•t +IP 7"-'V:7 :S :95vt..^, IiiAL:. IMPL:V PE]."w:3 Z.2f:¢O:,_ <br /> T. <br /> 'HORS�R'S �M4^�ISRT:CY _X45 nr <br /> A44L:CAA:'S SI09A:_i.E: <br /> BILLING INFORMATION: <br /> Indicate the responsible parry to be billed for additional EHO staff time expended beyond permit payment <br /> ;overage 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 Address , Phone 4,2f- ri � <br /> 3:cnatu re <br /> r??CO3. <br /> -zvisad 'i3iG2 <br />