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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3a'Ft COR <br /> ,TTOCKTON,CA A5202 <br /> APPLICATION FOR UNDERGROMD TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> TH S PERMIT EXPIRES 9C OAVS FROM THE APPROVAL.DATE. DO NOT WRITE IN ANY SHADED AREAS INDICATE PERM:T TYPE HELoW <br /> -__TANK RE-ROFR -_P�P(NG REPAIR/RETROFIT —_UNDER DISPENSERCO <br /> NTARCME VT P.EPA:R/RFTROFIT <br /> ---- <br /> --- <br /> : BDA SITE i --------- ------. <br /> -- <br /> . <br /> '-'--- ; PROJBCT CONTACT i IMLarim L i <br /> ♦-_______ ______'---^-__-----__. <br /> : iP <br /> FACILITY NMt � O ._-------------------_ <br /> --__'_ _ __ <br /> _ -_ __ ____- ---�1 49------- <br /> ---- ----- -mo'--o--_--_ <br /> - <br /> ------ --------- - S:__ <br /> L : CROSS STREET ---4 '��r�e.rc��- ' -�'' <br /> "� �T <br /> E�O <br /> : T I OYNSR/OPH RATOR --_____--_--------------_---_---- -___. <br /> Y : <br /> RIHs t <br /> i---*----------------------------- ------- '71�{� <br /> Z C�� � <br /> o . CONTRACTOR-RAilY �_�► rT t -- --------- -- <br /> ------------------ - ---------- <br /> CONTRACTOR <br /> ------ ------- <br /> 0 <br /> T ; ----- ------- !�(cc�`a Ta�.-1_" Q ST CkLIc rMURE �C� 7=ate 5 p ---- <br /> C----------------------- -------------- <br /> A :----------------I—TI T - i•?L'�is Lam! 'S. t v:vt' : YORK.COMP.r -_---_ -- _ �,' • <br /> --- --- _ --- -----�------------►5 <br /> C arYta IRPOIRRArlal --------- <br /> _ •------------------- <br /> R �_-----------------»--_ PHONE t <br /> ------------------------------------------------------- �-------------------— <br /> - --- _ <br /> . ...... ....... .. _________ ._______CHANIC_____ RSD CURR3urt.Y/VRINI/I <br /> T- - 1D i _..___ TANK SILL -CAL9 $TO ODSLY ( DATE VAT I1I6TALLSn <br /> 39- \ _ I O IL Qi-7 U�- <br /> T 39- 1 1 Off— t✓L. ._.__..__- <br /> ' A 39- -A -- <br /> K 39- - 1 ✓� <br /> 39- <br /> L _ .1PPROl'BLS APPRDV3�I WTTR OOKDITIW(S) DISAPPAOViD <br /> X PLAN RSVXRWM (S6R AT"ACHlOLU7' NITH COMDITIOCSI 2-k DATE <br /> IO <br /> ADFLICANT RUST' PBRFOAN ALL Ni.BK :N ACCCR*DAILCL %17_1 SAY JCIAOUI3 COUNTY 0111018ANCES. S-'ATZ L-kWS, AND Rill-Rs AND 5tILUUTAr1OIyS Cr <br /> SAN JOAOUIN COUNTY, EL'VTR-'W"KNTAL HYALTL' =PARTW;ZNT. OFRIHR OR L2CEN3N0 A5FNT•6 6IONAT::Rs ':BRT;FLEE 'IRE POLLgWINO: -Z CIIRTL FSf <br /> -;LUT iC THY PERF�OM4ANC1 OP ".•HE WORK PCR NHICR THIS PERp4jr !9 ;Sst D. I SHALL NOT EMPLOY .'vCr PtTiAOI: IN SUCH A RAHXBR AS TC <br /> iISCCHI SUBJECT TC WORKER'S -,*4P8R9ATZOt7 :.AKS OF CALIrORHIA. 0KS'RACTOR'9 HIRING OR SL"BC:1N:'R.L'T 11,'G SIGHATL2RE CBASI LIES 'LEIt <br /> FOLLOWING:NG: CERTIFY LA;fS ::,I CA:, -OIWIRI•LgI10E OF THE WORK FOR WV:LH THIS PMWIT IS 2S=, S1-;7`:, gf4P7L)Y PYRS(WS SVWECT TC <br /> WORxBx•s �I(PffiSATZOK LA:is OF CA:, - . <br /> APPLICANT'S SIGNATURE: - _ �• TITLE <br /> ---- <br /> - - -- <br /> , <br /> --- -"--------- — A -� /(--k- <br /> BILLI,tiG INFORMATION.- <br /> Indicate <br /> NFORMATION:Indicate tie responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party des gnated 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 /> NamekL)� cru z _ 'Address ��Cv`aY3�►rs,�..�s�S- [ „�...c�� Phone # <br /> Signature = - <br /> EH230038 <br /> (revised 1/31102) <br /> 1 <br />