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08/29/2006 08:27 20946F '3 <br />08/22/2006 12:55 90947677114 <br />EHD PAGE 03 <br />SHIRLEY E WIFD WNTL PAGE 02104 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JQAQM COUNTY <br />384 East Weber Avenue, Third Mor, SWdita, Oalitnrnia 95x02 <br />Telephone: (209) 468,3420 Fac (209) 46B -U33 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />Tris PsFw a XKmS so PAYS FRDNI:d: APPROVAL am. UDICATS Patwrrew B=* <br />F <br />&PA 6k0 # Pre)aet Ctudac4 & Tetephorw # ^f . <br />o <br />Patty r+ameXePhone 1! <br />Addrmea <br />sow <br />Tcmea <br />Y <br />ownwiOperator <br />O <br />GoMragdr N2trle <br />N <br />T <br />Ca+tra<1MrAd91'eB6 GMbw i( CA WCff' A Cdess <br />IL sorer n % S'** / wadF #, f E/SG /h <br />R <br />T <br />ICC TaehntGana Clitfkadan Number $ PJ/ <br />a <br />IDC ITlatalkr`a Certlfluatbn Numberb S/ ? — Lt ate <br />TanklD# Tank Size c-I'mmbab9tond DLdeUSTlnsWil <br />Cunend0remau* <br />A <br />N <br />K <br />p <br />L-lopmvez rWEd wah DarldltlOnB 117VBd <br />L <br />(gem daChmantVJhhconddlans) <br />N <br />t 7 <br />-Rlen.i?Bviewers Namr • lV G _Dehj �, • 2�1•-�q <br />APPLICANT MUST PSWORM ALL VMX IN ACCORDANCE LNTH ON JOAMN COUNTY ORDI WTCES, tn'ATE LAWS, AND KLU4 AFD R864-LATl*'* OF MN <br />jWxIm COUNTY. TIE PMORMANOR OF`W%OORRK POI�V*19 r" IS LRSUEm, I SKALLtJC MpLaaYAAOWNER OR ucENsm Ar,9411S IGNATURE iaYWFU40V INC WCHH A IJA1RIS THE AS S -Y0 <br />_�te.lEECCl70 <br />PERFORMANCE OF YH WOR FOR VOCHH7WI PERM17,1G ISSJSL,IaFIAAUEMMPLO�YPFRiFi(RE SUSiEGT 7'O VKAil�i3 CGAIpQJB/.TION <br />TTVAT�IN TM <br />OP OALIFORNIA" <br />— ia'°.Z <br />aFP+ lBk °re <br />Indkote the raspM01a PaKY fO be billed for addRWnal EHE stnif tune eupended beyond permit Payment CMMraW Par %MK N <br />th0 pally designated beim is drorent than the Pem18 epplkant, e.4. prcpatty OWW, ft Party MUO adknoWedge thfa <br />rommftsrbBSv idr4h9 bBBnebv sidnaWV and date below. <br />SIGNA <br />EH220M (iaAmd WN) <br />Fl <br />0.1444 6-7-Mic <br />