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'SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> - 304EWEBERAVE.3-FLOOR. <br /> STOCKTON.CA 85202 <br /> APPLICATION FOR UNCIQOGROUNO TANK RETROFIT.OR PIPING REPAIR PERMIT <br /> THIS PERWIrEtPIREB 00 DAYS FROM TMEAPPROVAL DATE. OO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _--:TANK RETROFIT PIPING RBPAIRJRETROFIT__UNDER DISPENSER CONTAINMENT REPAIRrRETROFIT <br /> {•YW RYTL - T PROJECT CONTACT 4 -MEPRQUE-------- 1 i <br /> P ------TY.IIDME <br /> I . Ty <br /> 1 i AOORe66 .3'1 Yjry.__ <br /> yAtu <br /> i. L i CIi0S1 6'IRELT _— <br /> I __—_.-___—_—_—..'..-______—___---_____—_______-_____—__—___--_-_________-----._—_____—____-I <br /> t T I ONNYR/OPERATOR t PEONS P <br /> Gee�vn� I4-836-94a i <br /> -- —�^��.,��}}�—�1 { r -�- -----------— ------------ --- ---- <br /> I G COMTRACTOR NAMB - <br /> 1" IS <br /> ----- --- t PEOIfR E oti . <br /> I IN Cm1'I'MCTOR JO:I.I _ Q C1 f� I CA LIC • 14 —- 6 T a'u'U C I _-`'(J z �G <br /> amu`—►�n_/-*--e l•..r1�Qnsq'- �— - RSA - ' M'pls1�--�!1�-- <br /> i A I INEOKtO! S-.1�1..=V-Yc�!t. s5d..!lA7SJ. i`SA'r_4S_=A3.�_`\a.X- - ------ - --- <br /> { A I•-'-------- - --•---- '---- -- ---- - <br /> C i OTHER INFORMATION <br /> __—__—------------- <br /> A , PROMS WI <br /> +•••I11 tt Il lflllltll t'I:111 1:llllllll_—--------—----------------------------------_-----------------------------------—------._I <br /> I I .TAPE m P t TANR6IZE ORENICALS STORYO CORAERTLY/PREVSOOaLY 1 DATE OST InSTALLYO 1 <br /> i ' 39- 1 I t <br /> T 11P- j <br /> A 39- <br /> i Y 139- <br /> R 139- <br /> t I i!• I I 7 <br /> •••d'Ili 11 tl IIIIFt{,IIII Ii I'I n 't I I,I IIIII,I:I;I II I it ll It tl It It 1.1 l'I I'1 it it:if 11 <br /> taI , <br /> I L 1 - APWtOF® APPROVKE RITE CORONDITION _- AZEAPPROVED <br /> I A '1 ( ATTACTARMT NSTE ClmnlTiapc) DATE <br /> r n PLAN RYFISHeRA nA97II 1,ry NG, � , <br /> „��; <br /> APPLICANT MOST PERFORM ALL WORK IN ACCORDANCE NITS HAH SOAOOIN COONI'Y OROLNANCES, STATELAWS, ANO NVLE6 AND ,,,,,T,= or j <br /> SAN JOAQOIN COONTY, 2WIRWt�NTAL NEALTR OEPAAT W, ONNER OR =CPz1SED AGENT'% SIWATDRN CSRTIF26S T FOLi.4WO: •I CERTIFY <br /> TRAT IN WE PERFORMANCE OF T. WCRK FOR MOM TNIS PERMIT IS ISSUED, I SEWS. NOV EMPLOY AEY FE of IN EDCR A MANNER AS TO I <br /> BECOME SOSJYCT TO WOREER'6 COMPENSATION LANs Cr CALIFORNIA.• CONSRACTOR'S MIRING OR SOeCONTRACTIIIG 6ICNATORE CYRTIFT= TNY <br /> FCLLONINO: "I CERTIFY TEAT M Ttic PERFORMANCE OF TRS WORK EON w ICE TNIS PERMIT IN zSSDEO, I SHALL EMPLOY PERSONS SOEJECI TO i <br /> WORKER'S COMPENSATION LAWE CE CALIFORNIA." <br /> I. InnTTn1mIF1 rITllOtIIlI1Ri11 MIM j <br /> sniff i <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 parry must acknowledge this responsibility for the billing by signature and date below. <br /> Name&u rUiI1-e7aQJ1ortddress 086 QUivtvl Ave ISgA,-6M one# <br /> Signatureg c �w ✓r' etws-i—F� <br /> EH230038 <br /> (revised 1131/02) <br />