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- ee ttlf�ano nv:nt �eya �n.t Etw • PAGE 02 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �w EWSIM ave,q%¢FLOW <br /> STOCKTON.CA 85202 <br /> APPLICATION FOR L VPGROVNO TAW RETROFIT,OR PIPING RgPAIR PERMIT <br /> TMI9 PERMIT M% RSSBObATq FROMTi18APPROVALDATE. 00"M'TE W ANY SMADED AREAS.INDICATC PORA¢T TYPE lELDw <br /> _,iMk RETROflT ➢RING REpAlP1REi1t0PlT_UNDER DISPENSER CONTAINMENT REPAIRIRWROFIT <br /> ..............t. ra AC 00 —; ,_,� ------ -- ------- <br /> -._— <br /> t • n,e fuer_ ��. .....�.... - a ------ZELEMCY[��{!GG Dr(----- <br /> -""........ <br /> 2 wale <br /> . .0 cP IF4 <br /> — — — ............. <br /> I CONTA.CTPA ..M6 <br /> ........---•_ ------- <br /> P"031 <br /> t CONTRACiOA AOpuL¢ - T'^"'•"-*�-=•p- <br /> S PF . �7` CA LIC I /p I CLAsa <br /> I INSVK - _• ••.. ................�j _p - _ _ <br /> �4'... .yT=1L(_.CFti....-----'--. uolu(.CUn.i ... _. ,.. <br /> 0'D!C} INPgtkATiYY __• --------j-_ <br /> _ ^J_ <br /> ..................... .. ..` ____ ___ __ _____ __ <br /> _ . <br /> .....................--....._ __._••_._-,......--I•rmNa•A ..._._._..---_•-_•_•__.-. <br /> TANX xO K RS[[ _ <br /> 9T0A[p CVKRLr-vTivn�JI0VD4[ •WiD WT :YYrALL¢0 -! <br /> I I <br /> 1:::I:i�:11111 : ;;.I .;U:11 ::11111 1 II 11. 1 <br /> .iillf t7-, <br /> ,:;. II: ... :.(I IIIT�I;;If Ij11•l„�,T: <br /> % �•. �iROYtD A �YtclATTR AVE00 7RIWETS <br /> CadjYDtAWIaI) �• D1;[ApP[OVSD <br /> K DLAY RYYIFYYKa NAME <br /> •-. ob:.I;I II 1111',:111:fill: I.;,::I 111 , 11::!1,IJII11• IL'tI,1:a: :r::1;;.u::::1: ::r•,: : :• :ICJ::1:';r <br /> TCAuT NVIr '=MEF ALL KORA SP ACmRDANKV PISM [AA TOACDIN It 0"WAR Ed, STA” LAY[, AYO AVLDY AND kecOLATI OPB pr <br /> aU THE Is Y, ev✓I AATR . Ygiin CA LS;kIRaD ACLNS's FIONAlDKD CRIITIFLDD 7NC WLLgkIRO: •I Ca]x2¢r <br /> e i C 05"ECT TE6 YOKK 4Ni IIT Tf faaV[D. t PWiG NDS BR[VjZ ANS rigaDN '!A aVCk A MANNER 6B TO <br /> A[AA'1 LORPTNYATI WE Or <br /> �D ICVIUG' YI CORY SWT TRI me CO W TINT [ORK Po MUNTAACTOK1D RIAIeC 01 DVACCNTAACSSYc 5I01AmKY CDKx;tI[a TMS. 1 <br /> IquArz S COki[YAATI [AITTOyY, IM 1475 TYKkxf¢2�^s viVLD, I'¢NµL 24"Wy VE"'M 'pUJWT So 1 <br /> .. \PDL:�fJrt'c FLCNATCAi1 SIr1.c 1�Q16� �AI���R J—'�—��! <br /> ................... <br /> E31LL IVIG INFORMATION: <br /> Indidate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> covf rage per tank. If the party designated below is different than the permit applicant, e.g, property <br /> own r, the party Must acknowledge this responsibility fort billing by s nature and date below, <br /> Nam '5A A n9OIS Address �j0 � — 4`��' - <br /> --� Phone# 6 <br /> Sign ture. rL <br /> EHZ 0038 <br /> (revi 1/31/02) <br /> Y 0� St'3 SO�CO 9TOZ-LZ,OT <br />