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-SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL. HEALTH DEPARTMENT <br /> 304 E WESER AVE.30 FLOOR . - <br /> STOCKTON.CA 85202 - <br /> APPLICATION FOR UNOERGROUNDTANK RETROFIT.OR PIPING REPAIR PERMIT <br /> THIS PERMIT E&PIRE13 00 DAYS FROM THEAPPROVAL DATE. OO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: - <br /> ._TANKRETROFIT ;PIPING RERAIR/HIETROFlT-_UNDER DISPENSER CONTAINMENT REPAIR/FitTROFIT <br /> -------------____---------—------------—-----------—----------------------—---------_.------ <br /> I I IPA BYTE } I- PROJECT CCRTACT A TELEPRCWE } i <br /> 1 F ; FACTLxTY.Hmroi VOA _ - -------------� cxae-� <br /> IA«------------'---- � -------- ----j------�I-----•--------- - -✓� - -- !7-/�- - <br /> ADOA866 .�,.J S. _ J:^ - e' ._YI �?�_�•- -1 <br /> n -SS 1 1.--•-___•------------- ---------- <br /> Mss STREET I (tl(,� [� '-DSI <br /> Ix «-__------_--_atm_ _____`_1�1..�{_--.... u_-_-_-._-___-_______________--------..-----------._-__-_-__ 1 <br /> I T I.OIffiNx/OPRAATOR I PHONY } - - <br /> �a4— �3a -0370 -i <br /> I C CalTRACIOR NAMWp. ------ <br /> ?W✓'. --S S-----`._'---- - I PRORS II p-04 J'lQti3-1- I <br /> I s ComTAMOR ADAREss __ QSf f� I CA LIC r I eLAss$ Cf��1-•(per. _Zf}IG <br /> _"�^ ' �s>u.-------------------- --� -------------A' D � -- <br /> I N I TIINORIDI � N�.�X1ASSd.'�tA!?_Sl4�.f 1 4?1A ----------„-NOS-`Or;`.# <br /> ' C i OTHER INFORMATION <br /> IT a-•-__—----------------..------- ---.-__-_--------------------------,i.___-------- ---_ .------1 <br /> 0 i - i PRONE r _-______._-. i <br /> 7 R s----- <br /> ---------------------------------------------,-----------------.-------..-______-.___--_-_----_--_---------I <br /> 7 7 -._.1 PHORS }___. <br /> «-•-tlititl lCllllirt ll tlfltlllf lull------------------------------------------ -----.----------------..--- <br /> 1 I -TARG TO r I Twx SIZE OREMICALS STORE= cOU1aRT WPAMOaBLY 1 DATE CYT INY NZW I <br /> 1 1 as• _1 I I 1 <br /> T 1 AP- I <br /> tNI so- <br /> r.I1. I Ili tl!I a7,ii 7 <br /> 1 p I I <br /> I L I APPAOv® APPROM WITH COHOlT20M(S1 AISnPPROVED .�IH � ��/ <br /> i A I - (WE ATTACEM@NT N TN C�TTIONS) DATE t(�-L-Y-I/ 7 <br /> I'IS” FLAIL NNvzxmks NAME t NG <br /> --••f1111It 11111.n;:E'riu;,.l:T� i �tlnu ;:l!�IU 11;11Iu:1nllf;nin In111 :n11111111„r•1 'r-' <br /> ( APPLICANT HURT.PERFORM ISL NOAH IN ACCORDANCE NITH EAE OOAOOIN COONTY OROItIAMCE6, STATELAWS, AND ANLEY AND RECVLATTOKs OF 1 <br /> I SAN JOAQVIN COONTY, RXVIRONfRli HEALTH OIPARTMEMT. OWNER OR-I-ICENSAO AGENT'^s SILTHATWE CAATIFTES TEY FOI.I.OMING: •I CERTIFY ' <br /> ' SRIT W TRE QERPORMANCE OF THE NORK FOR WHICH THIS nxMIT IS ISSOED, I SH NOT P.MPLOY AHY pERxai IN WCH A F ER RS TO I <br /> I BROOKE SONCTCT TO WORSEA•S COM WSATION LAHS OF CALIFORNIA.- CONTRACIOR'E HIRING OR SORCONTxACTING SIGNATORY C�FTSS THE 1 <br /> . vOLLOMOTG: "I CERTIFY THAT M THE PRAFORMANCE OF i'R.s WD vox NIXON TRIS PERMIT IS IsANIIL, I SHALL EMPLOY PERSONS GONJE= TO I <br /> I WORKER'S COMPENSATIC¢I LAMB M CALIFORNIA. <br /> I I <br /> 1 <br /> 1 <br /> 1, IniHTnuvrn nTrntU 111N, - TTttlfi 1 <br /> BILLING INFORMATION: <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 /> yUi(2.5RJ1&1a thgfiAddress 68th Q�iPtvi Acs � gs <br /> rd- <br /> Name <br /> ,,gy�pp �. G.t. � Phone# `kg-a13-1003 <br /> Signature <br /> EH230038 <br /> (revised 1/31102) <br /> 1 <br />