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SAN JOAQUIN COUNTY ° � nln2rl ENVIRONMENTAL HEALTH DEPARTMENT ._ 904 E WEBER AVE,3fO FLOOR V4 MAY n 4 2004 STOCKTON,CA 95202 I�' APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERA;II ENVIR0fvv1LIdT jtL,�J H PERMIT/SERVICESTHIS PERMIT EXPIRES 90 DAYS FROM THE i PPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INC ICATE PERMIT TYPE BELOW; _TANK RETROFIT _PIPING R':P)JR/RETROFIT --_UNDER DISPENSER CONTAINMENT REPoUR/RETROFrr __________ _____________________ I I mA ua x '--------------• I ______________ -._____..___I ------- ------- R TEL-PHwE Y I - _ •-------•---I P I FACILITY Nums:---- -I PHDHE Y I A .------ GQUNIRY._MARKE TPIJ `Eass _fi--••_-_-------------------- -------- � II '� --- 1789 W. CHARTER WAY, STOCKTON, CA 95206 I --• ` I amss 8"�P FRESNO AVENUE j I I ------------------------------------------------ ---..-----" ------------------------------- ----------- I T I owax/oP®+Arae ._. ..----- -I ITL I PFgNe Y --••------------•-- -----------------------T E--LER 5 -------------- ----I- (2 0 9) :37- 350- 8 I JIM II -----------------------------------------------------HOBLITZELLI � (209) 9.-+3 7793O -------------------------------------------------- ----------------------------- _ --- - . _ _. .. -------------- --- N I CO+rnAcroR ADDRESS I Xj0jj1�STOC;<TON, CA1 _Q33.'..______.ICI ' ---I T -'-------•--------------B--O I R I IN90PRR I WORK CDDID.Y A I----------EXEMPI--------------------J I.C...#.__36.5Z34---------- ------•.__...------ EXE�13T I ICI voDRt DDwR Ww I I IT ___________________________________________________....____.___.___._._.__._.___--__.-_.._------___-___-._ _ - - Y I R .._____________________________________________________________---------------------- ----_---_______..._-_._...____.____..______I I i I PNDBB M I I----------------------...-------------------------------------_.._.._------.._.__...-_--___.____.I I I TxNK IDE I TANK SIW I cu:Sxl AL9 b10RED CDMBNILY/PRBVIQI9LY I Iain UST INSTAu.ED I I 139- I T L 39- L A 139- I N 139- IRI I 133- I I 1. I ---IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIII1111IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIInIIIIIIIII111IIi1I11 IPI I 1 L I APPROVED AIV VED NITH ON _DISAPP I I A ITIAD�ITIDNE) In I PIAN AEVIBNOB NMB _ �/--v� MTB i ---Illlllllllltllilllill ILII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIitlllllllllllllllllllll III!..1 IIIIIIIIII 111111 I I I AP�CANI'MIYT DBRPOIIII ALL NONE IN AONADANCS WITH 8AN IOAaVIH MW11Y ORDINA11C89, 91'ATB LAW9, AND RULES NII I l'AJLATIws OF I I ERN J0,0=OJ(WIT, ENVIA�n HEALTH DEPARTIAM. (0MR OR LICBNSBD MI ,S EIONATDRH =TIPI66 THE POLIYE.IDq: •I LTD[I'IFY I 1 TMT IN To FEReORKNOCS OF SIB NORE FOR REICH THIS PURNIT IB ISSUED, I JIHJ.I,NOT ED@IOY ANY PERSON IN SUCH A MANNER AS TO I I RR(vB mw=m Ram" m Igag TIw LAMB of HIRINO OR.BOHmNI'RAC m SI@lA.TM QR(Tle3as THE I I POLIlAYlNO. •I ==n THAT IN THE PERPOW3ANCR OF THL FCKK POR WHICH THIS PERMIT IB ISSUED, I SHALL EDIRLVY IMXONS eo>r'1 TO 1 I Ntfit R•y mm>aISATIw I"$or aB.IPORDIIA.• p' I I I APPLICANt'9 BIwATORE: ✓_! TITLR [L YI/ an -- ---------------------_------------------------------------------______-----------------------------------------_. ............ BILLING INFORMATION: COUNTRY MARKETPLACE 1789 W. CHARTER WAY STOCKTON CA 95206 Indicate the responsible party to be billea for additional EHD staff time expended beyond permit payment coverage per tank. If the parry designatE d below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsit ility for the billing by signature and date below. Name PAT EHLERS Addre, h, 1789 W. CHARTEY WAY hone#(209)870 3508 OPERATOR 1