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-SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL, HEALTH DEPARTMENT <br /> - 304 E WEBER AVE,3NP FLOOR <br /> STOCKTON.OA 05202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT.OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM TMEAPPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS.INDIOATE PERMIT TIDE BELWJ: <br /> ^TANK RETROFIT ,,;PIPING R60AIRn2ETROFIT •—_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> .—---------___—-----------_-------—---------^---------_--__ <br /> 1 / -DPA MYTE { - I PRO,TECI CONTAcr L TELEPHONE » , <br /> I P <br /> II AC I APADCOTR-¢-6-6- —��I.�• -U- _i• _ �r. —_yy-� /s, _ _—__..---_.--._._____q1______AI�_.!P_.R_!J__�_E__D p _QE----___1_D__—_31 C-I--______--_-_- <br /> ---__ _II <br /> 1.L CAM STREET K 0 MAL- <br /> 1 7 I-O14oml/OPDIIATOR I PHONE Y —------ <br /> -' <br /> ..:�� Ctti2------ ✓► ------------------------•- _ aa�-say-3I YI _ <br /> 1 c c�rrRxcroa�ina,�gl5�s��9Z'i��S�U_l.S-_-- •---- 1 PROAs »1�Qk oZ13:'_�p�13 <br /> - -------------- ----•-------- - <br /> 1 ■ CmPfMCTORADDRESS '` /�,�,1.I,I Q,.,, �^,. /� — <br /> I �f'� 1 CA LIC » COAG6'BLC/.II <br /> I R I II±EDREA S 2. 5 �. K.�SL!]hKl�FVX1L!•---------•-----„-DORS.COPID.i 1 1 1 8 -"'a•-Z- ---I <br /> 1 C I OTHER INPORK1,TIOM - <br /> I r .-----____.___--__----_—___________ — <br /> ' - t I <br /> 1 1 Pam C , <br /> 1 R r._—__—__-____..--•-.--.-__w ------______-_—__---_-_--.,.—_—___------_____------------------ <br /> PH= <br /> +••-Ilil:llI(IIII II1111111111111 It II_--___---..-,_-._—_—------—--------—__—---------1 -- i-__-------___________—_-- <br /> ---_I . <br /> I I .TINA m R 1 TAD[EPEB - CSENICALS STOREN CORMIITLY/PRRVxOosLY I HATE OCT IN94A14L= I <br /> IA • D►- - t <br /> 1 D I Af- _�-.•�i � <br /> IRI IP- <br /> Sf- I I I <br /> +•••I1"fIi III I'I <br /> JFRIIII111III HI-I It { I 111 t.1'iIIIIIJ 1111 ii III IFI I11I111 i III II:II ii j <br /> 1D1 1 <br /> I LI _APDROV® •APPROVED MITE C0=2TICDAD <br /> IS1 _— PISPROYSD <br /> I,A I - (REE ATTACRHBNT WITH C�Dxixcne) i <br /> I IS PLAN amai uEE:x" ' W 1• <br /> H .W(T - - -DATE �0. o'p ri <br /> -I IIIIII IIIILII•':41. 1Lit 11 lu I 1. .;n II PII11!:n:l ull: nl a II:IIII11Tr�,li l:,1. :Ii.rTTT rIT('r� <br /> 1 APALICAWT HURT.PRMFCMH ALL KORA IN ACCORDANCE WITx Em a0A40IH COOWIY ORDINAMCE6, STATE LAWS, two =LES AND REGVLATIOPs OF , <br /> i CAN JOIN <br /> E C2RFVY, $CVIA�IONTAL IWALTx tlSPAATMENT. OWNER M =CsNfED AGENT'S SIWATORR CERTIFIES TI{B FOLLDWTNG: •I CERTIFY ' <br /> THAT IN TFIE PERPONm1liCD OF TRE MOR% FOR WKICH TIRE DSFKTT I6 I66DED, I SI NOT CHPLOY ANY PER9a4 IN SDCN A II&RNER AU TD i <br /> DECOKE Sa1JUCT TO WORE" a COIF SAIICR LANE OE CALIPORMIA.• CpNTRACIO¢,s HIRING OR 60HCOETRACT INO SI�T;xRz CxsrxrIEs xx1E 1 <br /> EOLP.ONINd: -I-CEWTI f TMT Ie MM PRAFORKANCE OF TCU WORK FDR WHICH TRIS PL jw is xs=n, I SftiL EnnLOY PERSONS SDEJECI TO I <br /> HOREER'C Ca'@EESATIW 1 N 13 M CALIFORNIA.• _ <br /> 1. SIIDTTn14Dl'O I WMIINMRI TT1'!161 <br /> RIF I <br /> BILLING INI'ORMATION: <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 <br /> owner,the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Sa7b: j:' tj L�,�usa,ddress (W) QUivtvt B�ue:� ?S <br /> evtPhone# `�g"a13-(0031' <br /> Signatures o C»w V 215A; 1� <br /> EH230038 <br /> (revised 1131/02) <br />